Gynecomastia-like changes of the female breast.

OBJECTIVES: Gynecomastia-like changes of the female breast are only sparsely reported and are not well defined in the literature to our knowledge. Our objectives were to determine the incidence, clinical presentation, mammographic findings, and the medical background of patients with these changes. DESIGN: Two thousand seven hundred nine female breast surgical cases from 1995 to 1999 were searched by SNOMED. Three observers further reviewed all cases with gynecomastia-like changes. Strict criteria were developed and cases that fulfilled the criteria were analyzed further. RESULTS: We found the incidence of female gynecomastia-like changes to be 0.15% (4/2709) of all female breast lesions, which represents an underestimation. Patients were usually young and had an average age of 32 years. The usual clinical presentation was a palpable mass with a size ranging from about 3.5 x 2 x 2 cm to 5 x 4 x 2.5 cm. Mammography showed either negative findings or a nonspecific density. Gross examination of these specimens revealed no distinct lesions. Histologically, the lesions consisted of ductal hyperplasia with periductal stromal fibrosis or edema. They were associated with fibrocystic changes in the adjacent breast. The patients had no significant medical history. CONCLUSION: We propose that the gynecomastia-like change is a specific benign entity within the spectrum of benign fibrocystic changes and that it usually occurs in young patients.

Megestrol and tamoxifen in patients with advanced endometrial cancer: an Eastern Cooperative Oncology Group Study (E4882).

To investigate the effect of adding tamoxifen to megestrol in the hormonal therapy for advanced endometrial cancer, 66 patients were entered in this study. Initially, 41 patients were randomized to either the standard progestin therapy of megestrol or to the combination of megestrol and tamoxifen between October 1982 and October 1984. The megestrol arm was terminated because of poor accrual and 25 patients were directly assigned to the combination arm. Among the 20 eligible cases on the megestrol arm, the response rate of 20% consisted of I complete response and 3 partial responses. The response rate on the megestrol plus tamoxifen arm was 19% with 1 (2%) complete response and 7 (17%) partial responses among 42 eligible cases. The median survival times were 12.0 months and 8.6 months, respectively. Only mild and moderate toxicities were observed on megestrol compared with more toxic complications observed on the combination of megestrol and tamoxifen, including a life-threatening case of pulmonary embolism. Although we could not carry out a comparative evaluation as intended, we conclude that the combination of megestrol and tamoxifen offers no clinical advantage over megestrol alone in the treatment of advanced endometrial carcinoma.

Ischemic colitis with atypical reactive changes that mimic dysplasia (pseudodysplasia).

OBJECTIVE: To describe reactive or reparative but atypical epithelial changes that occur in ischemic colitis. DESIGN: Surgical pathology files were searched for the diagnosis "ischemia, bowel." All cases were studied for reactive or reparative atypical changes. These were characterized and correlated with clinical information. RESULTS: Reactive atypical (pseudodysplastic) changes were found in 8 of 28 cases of ischemic bowel. The clinical history did not indicate ischemic colitis in 6 of 8 cases. In 3 cases, neutrophils in the lamina propria or acute cryptitis and crypt abscesses that suggested inflammatory bowel disease were noted. CONCLUSION: Ischemic changes in the bowel may produce reactive epithelial changes with sufficient atypia to simulate dysplasia. These may be associated with histologic changes that simulate inflammatory bowel disease, specifically ulcerative colitis. Since in most cases even the clinician is not sure whether the patient has ischemia or inflammatory bowel disease and because histologic changes of the latter may occur in ischemic bowel, there is a danger that the atypical reactive ischemic changes could be interpreted as true dysplasia that occurs in inflammatory bowel disease.

Endocervical reactive atypia: a histologic-cytologic study.

Of 1,500 cervical tissue specimens, 27 cases showed histologic changes of reactive glandular atypia which we defined as endocervical cells with large hyperchromatic, often irregular nuclei, which did not fulfill the criteria for endocervical adenocarcinoma. Eighteen of these 27 cases had preceding or concurrent cervico-vaginal smears. Six of these showed cells which were similar to those seen in histologic sections. The cytologic characteristics of these cells are defined. To determine if atypia is related to inflammatory-regenerative changes, 29 cases of endocervical polyps were examined, of which 11 showed histologic changes of endocervical reactive atypia; 4 showed these changes cytologically as well. Twenty-eight cases of routine hysterectomy specimens were examined, of which 2 cases showed endocervical reactive atypia, which indicated that the atypical changes were indeed reactive. Nine out of 27 cases were associated with hormonal usage. Fourteen cases were associated with squamous intraepithelial lesions or evidence of human papilloma virus. Follow-up of our 27 index cases revealed no progression to adenocarcinoma. These findings indicate that atypia, as we define it, of the endocervix can be due to inflammatory-reparative changes or possibly related to hormonal usage, and permit its separation from precursor lesions of endocervical adenocarcinoma.

Traumatic pseudoaneurysm: a possible early lesion in the spectrum of epithelioid hemangioma/angiolymphoid hyperplasia with eosinophilia.

We describe a vascular lesion that develops secondary to trauma (pseudotraumatic aneurysm) and study its relation to epithelioid hemangioma (EH)/angiolymphoid hyperplasia with eosinophilia (ALHE). Four lesions are described, all with a distinct history of trauma to the site from which they arose. They presented with masses in the subcutaneous tissue of the head. They were studied by immunohistochemical methods to identify their component cells. The lesions all demonstrated marked thickening of the wall of small and medium-sized arteries, with capillary vascular proliferations. One lesion demonstrated increased eosinophils. Myxoid changes were noted in all lesions. We hypothesize that these lesions may represent an early form of EH/ALHE.

Gallstones implanting in the ovary. A complication of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the treatment of choice for most patients with cholelithiasis. The spillage and loss of gallstones into the peritoneal cavity is a relatively common event occurring during these procedures and has generally been thought to be of little consequence. Although in many cases this does appear to be true, there are uncommon but nevertheless noteworthy sequelae being described. Complications reported have included intraperitoneal abscesses; foreign body granuloma formation; and, more rarely, cholelithiasis of the ovary. We present the case of a 30-year-old woman, who underwent diagnostic laparoscopy for infertility 20 months following a laparoscopic cholecystectomy. Gross findings showed tissue deposits that suggested a malignant tumor. Microscopic findings revealed gallstones embedded in the ovaries and the pelvic peritoneum. To our knowledge, this is the longest reported persistence of gallstones involving the ovary. A full case report is presented, and the possible complications of lost laparoscopic gallstones are reviewed.

Double-blind, randomized study of primary hormonal treatment of stage D2 prostate carcinoma: flutamide versus diethylstilbestrol.

PURPOSE: Patients with stage D2 prostate carcinoma are often treated initially with hormones to decrease endogenous testosterone. Therapy with diethylstilbestrol (DES), leuprolide, or bilateral orchiectomy has been reported to be equivalent. DES is the cheapest preparation, but has the potential for serious cardiovascular or thromboembolic complications. Flutamide is a novel antiandrogen with fewer side effects. PATIENTS AND METHODS: The Eastern Cooperative Oncology Group (ECOG) conducted a double-blind, randomized study to compare the efficacy of flutamide (250 mg three times daily) to DES (1 mg three times daily) as the primary hormonal therapy for patients with stage D2 prostate cancer. Patients were stratified by performance status, disease sites, and history of cardiovascular disease at randomization. RESULTS: Forty-eight patients received DES and 44 flutamide. Patient characteristics were evenly distributed between the two treatments. The overall response rate was similar (DES, 62%; flutamide, 50%). Grade III or worse cardiovascular or thromboembolic toxicity developed in 33.3% of patients on DES and in 17.6% on flutamide (P = .051). Other toxicities were similar between the two treatment arms. However, DES produced significantly longer time to treatment failure (26.4 v 9.7 months, P = .016) and longer survival than flutamide (43.2 v 28.5 months, P = .040). CONCLUSION: As the primary hormonal therapy for stage D2 prostate cancer, DES caused more serious cardiovascular or thromboembolic complications than flutamide. Despite this, flutamide was not as active an initial agent as DES. However, the effectiveness of flutamide in conjunction with other agents compared with DES remains undetermined, and the optimal initial hormone therapy of stage D2 prostate cancer requires further studies.

Mycosis fungoideslike T-cell cutaneous lymphoid infiltrates in patients with HIV infection.

Cutaneous patch and plaque lesions, and erythroderma may suggest mycosis fungoides both clinically and histopathologically in HIV+ patients. However, in some cases, this diagnosis is questionable. Five such cases are presented. When we compared these cases with cases of mycosis fungoides unassociated with HIV infection, we found less concordance among dermatopathologists in making a histopathological diagnosis, a greater proportion of CD8 than CD4 T cells in the cutaneous infiltrates, and no instances of demonstrated clonality of the cutaneous T-cell infiltrates in the HIV+ group. We conclude that CD8 T-cell predominant dermatoses may simulate mycosis fungoides in HIV+ patients.

Carcinosarcoma of urinary bladder: report of 5 cases with immunohistologic study.

We studied 5 cases of carcinosarcoma of the urinary bladder. Immunoperoxidase studies were performed to identify the nature of the tumor and to establish the diagnosis. We suggest that these tumors represent a transition of epithelial to mesenchymal malignancy. Three of our patients had a history of radiation therapy prior to development of carcinosarcoma; of which 2 had a long interval between exposure to radiation and tumor development. Radiation is a risk factor for endometrial carcinosarcoma, and in this report we strongly suggest such an association for the urinary bladder.

Polyomavirus in the urine: follow-up study.

This study was undertaken to determine the significance of polyomavirus nuclear inclusions in urine cytology specimens. Thirty-two such cases were identified and patient follow-up was instituted. We have determined that there is no detectable urologic damage in such patients. In a minority of cases inclusions were found in subsequent urines but they ultimately disappeared within 3 mo. In a minority of the patients (35 percent) there was evidence of diseases associated with immunosuppression or administration of immunosuppressive drugs.

Crystalline bodies in cervical smears. Clinicocytologic correlation.

We examined 6,132 cervical smears, applying strict criteria separating hematoidin cockleburrs from crystalline bodies. We found only crystalline bodies in 37 cases. There was a significant increase in the incidence of crystalline bodies in women taking oral contraceptives and in pregnant women. The bodies were not associated with an increase in complications of pregnancy or of abnormal births. A review of the literature led us to the conclusion that in cervical smears two types of crystalline structures may be found. One of these is the hematoidin body, which is related to hemorrhage during pregnancy and is probably associated with an increase in complications of pregnancy or abnormal births; the other, crystalline bodies, is not. We also conclude that crystalline bodies are much more common than hematoidin bodies. We found an unexpectedly high association of crystalline bodies with low grade squamous intraepithelial lesion (CIN1) in cervical smears.

PIP: During January-May, 1990, in New Jersey, a cytopathologist and physicians at the Monmouth Medical Center examined 6132 cervical smears for crystalline bodies and hematoidin cockleburrs to determine whether a difference between these two structures exists. None of the cervical smears had any hematoidin cockleburrs, which are associated with hemorrhage during pregnancy as well as with a greater number of complications of pregnancy and birth. Crystalline bodies were present in 37 (0.6%) cervical smears. They were 15 times more likely to be in the cervical smears of pregnant women and in women using oral contraceptives (OCs) than in nonpregnant women or women not using OCs (p .0005). None of the 19 pregnant women with crystalline bodies suffered any pregnancy complications, fetal loss, abnormal births, or isoimmune hemolytic disease. Crystalline bodies were identified most often during the 2nd trimester. The size and complexity of the crystalline bodies were the same in pregnant and nonpregnant women and in women using OCs. The number of bodies were the same in pregnant women (1-30) and women using OCs (1-35), yet were greater than those i n nonpregnant women and women not using OCs (1-5). 10 of the 37 women whose cervical smears had crystalline bodies had low grade squamous intraepithelial dysplasia. Crystalline bodies disappeared in some women after delivery, yet reappeared in subsequent pregnancies. They also disappeared in some women after they stopped using OCs. Based on these findings and a review of the literature, the researchers concluded that crystalline bodies are often mistaken for and are more common than hematoidin cockleburrs.

Cloacogenic carcinoma of the anal canal and associated viral lesions. An in situ hybridization study for human papilloma virus.

Five cases of cloacogenic carcinoma were analyzed for microscopic human papilloma virus (HPV)-induced changes and with in situ hybridization technique for HPV types 6/11, 16/18 and 31/35/51. Four of the five cases showed epithelial foci of koilocytotic atypia. HPV type 16/18 was present in four of the five cases. The surface epithelium in two of the four cases with koilocytotic changes showed HPV type 16/18. HPV type 6/11 was seen in surface epithelium in one case in which invasive carcinoma showed HPV type 16/18. This double infection with double morphologic expression could mean that the same behavioral pattern (anal intercourse) may contribute to both anal condyloma and carcinoma and, although patients with condyloma are at risk for carcinoma, condyloma may not be the precursor lesion in all cases with coexistent condyloma and carcinoma. Because of the similarity between pathogenesis of anal and cervical carcinomas, a periodic cytologic screening of anal mucosa could be indicated in populations at risk: homosexual men, patients with condyloma, women having dysplasia or carcinoma of the uterine cervix, and patients with immunosuppressive disorders.

A retrospective analysis of breast cancer based on outcome differences.

We reviewed tumors from two groups of patients with breast cancer, distinguished by differences in outcome. One group (85 cases) survived more than 8.5 years without tumor recurrence; the other 85 cases had recurrent disease within 2 years. Histologic and immunocytochemical studies on all cases were performed without patient identifiers and prior to review of clinical prognostic factors. As expected, lymph node and estrogen receptor status differed substantially between the groups, but menopausal status and family history for breast cancer did not. We noted that 27% of node-negative patients died within 5 years, and nine patients with four or more tumor-containing nodes were symptom-free for over 8.5 years. Histologic grade (degree of tubule formation) and nuclear grade (including mitotic rate) differed significantly between the groups, as did vascular invasion, including both lymphatics and blood vessels. Prognostic value attached to tumor border only when fat was invaded without fibroblastic or inflammatory response (P = .012). Subgrouping cases of infiltrating ductal carcinoma (not otherwise specified) was prognostically informative in the B subgroup, 69% of whom were in the rapidly recurrent tumor group. Immunocytochemical staining for c-erbB-2 was positive in 19.3% of cases, but was equally distributed between the two outcome groups. We conclude that traditional histologic parameters are highly informative, and that c-erbB-2 studies do not increase the value of histologic diagnosis.

Adrenal cortical carcinoma: flow cytometric study of 22 cases, an ECOG study.

Flow cytometric studies of archival material from 22 adrenal carcinomas demonstrated aneuploidy in 21 of 22 cases. Heterogeneity of nuclear DNA was found in 14 of the 22 cases. Eight of these showed distinct aneuploid and diploid populations, and 6 showed multiple aneuploid cell lines. The heterogeneity was detected because numerous paraffin-embedded samples of each tumor could be examined. No correlation was found between either aneuploidy or heterogeneous DNA content and patient survival, response to therapy, or hormone secretion.

Pulmonary calcification caused by Pneumocystis carinii pneumonia. A clinicopathological study of 13 cases in acquired immune deficiency syndrome patients.

Pulmonary microcalcifications were identified in 13 patients with Pneumocystis carinii pneumonia (PCP) and acquired immune deficiency syndrome (AIDS). Several patterns of calcification were noted including bubbly, plate-like, elongate, and conchoidal forms. All calcifications contained P. carinii cysts within them as demonstrated by Grocott's methenamine silver stain. In eight of the 13 cases, the typical intra-alveolar exudate of P. carinii was absent. Therefore, the calcifications were the only histopathologic indication of prior P. carinii infection. The above-mentioned calcifications are important because in five cases they occurred without a prior diagnosis of PCP, subsequent therapy, or prophylaxis. This indicates that in some patients there is destruction of P. carinii organisms with subsequent calcification, and this can occur without therapy.

Rotator cuff lesions: signal patterns at MR imaging.

The signal intensity patterns of rotator cuff lesions at magnetic resonance (MR) imaging were evaluated in 80 patients who had surgical correlation and in 13 asymptomatic individuals (14 shoulders). Six cadaver shoulders were examined with MR, and histologic correlation was obtained in four. All studies were performed at 1.5 T with a flexible circular surface coil. The accuracy of MR imaging in detection of full-thickness cuff tears (31 patients) was 0.95 and of partial thickness tears (16 patients), 0.84. The most common and accurate pattern for full-thickness cuff tears (22 of 31 tears) was a region of intense signal seen on T2-weighted images. Less often the torn region consisted of an extremely degenerated and attenuated tendon with moderate signal intensity or was obscured by low-signal-intensity scar. The intense signal pattern on T2-weighted images was also accurate, although a less common finding (seven of 16 cases), in the diagnosis of partial tears. Tendinitis was recognized as focal or diffuse regions of increased signal intensity or a nonhomogeneous pattern of increased signal often associated with tendinous enlargement. In some patients, manifestations of subacromial-subdeltoid bursitis was present. Tendon degeneration was also manifested as regions of increased signal intensity. Some similarity and overlap of signal patterns of partial interstitial tears, tendinitis, and tendon degeneration are observed.

Fine needle aspiration biopsy of cystic benign lymphoepithelial lesion of the parotid gland in patients at risk for the acquired immune deficiency syndrome.

Cystic benign lymphoepithelial lesion (BLL), a previously rare lesion of the parotid gland consisting of marked lymphoid hyperplasia with accompanying squamous-lined cysts, has recently been described in patients with the acquired immune deficiency syndrome (AIDS) or AIDS risk factors. Thirteen fine needle aspiration (FNA) samples of parotid gland masses from patients with AIDS (one case), AIDS risk factors (five cases) or denial of AIDS risk factors (two cases) and a histopathologic diagnosis of BLL were examined. The FNA features that correlated best with the histopathologic findings were (1) a heterogeneous lymphoid population, (2) scattered single and/or clustered foamy macrophages and (3) superficial and/or anucleated squamous cells. Most aspirates showed some combination of these three components. The differential diagnostic considerations, the clinical and radiologic correlations and the relationship of this lesion to HIV infection are discussed. Patients with parotid masses whose aspirates consist of some combination of squamous cells, lymphocytes and foamy macrophages should be questioned for possible AIDS risk factors.

Human immunodeficiency virus infection in women: report of 102 cases.

We examined surgical specimens from 19 human immunodeficiency virus (HIV) seropositive females and 83 females with acquired immunodeficiency syndrome (AIDS) to determine (a) frequency of opportunistic infections (OI) and malignancies, (b) differences or similarities between different risk groups, and (c) differences or similarities when compared with men having AIDS. A risk factor was identified in 86 patients (72 AIDS and 14 HIV seropositive), of whom the majority were intravenous drug abusers (IVDA) (74%) or had had heterosexual contact with a person with AIDS or at risk for AIDS (20%). The remaining patients were blood transfusion recipients or Haitians. All females were treated at Bellevue hospital, a large municipal inner city hospital. The conclusions of our study are as follows. (a) Women with AIDS develop the same type and incidence of OI and lymphomas as the general AIDS population. (b) The incidence of Kaposi's sarcoma in females with AIDS is similar to that seen in male heterosexuals with AIDS. A greater than expected number of epithelial malignancies were found in our population. Characteristics of these carcinomas included young age of the patients (average age of 40), unusually aggressive nature of the tumors, and tendency to occur prior to development of AIDS. We therefore suggest HIV testing in all young females (and males) who present with an unusual or particularly aggressive epithelial neoplasm. (c) The most common OI was Pneumocystis carinii pneumonia (PCP), followed by mycobacterial infections. PCP was seen in a significantly greater percentage of females with a sexual contact risk than in female IVDA (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

MR imaging of pulmonary parenchyma: comparison with CT in evaluating cadaveric lung specimens.

Magnetic resonance (MR) images (0.5 and 1.5 T) and thin section CT scans were obtained in 17 cadaveric lungs (11 fixed, 6 both pre and post fixation). Standard T1-weighted spin echo (SE) sequences were used for all lungs. In six lungs, additional gradient-refocused echo (GRE) sequences were also obtained. The MR images and CT scans were compared to corresponding gross and microscopic pathologic sections. In all cases, MR SE sequences proved comparable to CT for delineation of normal anatomic structures as well as a range of pathologic conditions, including both air space and interstitial disease. Although image quality was markedly degraded on GRE compared to SE images, they did permit visualization of pulmonary vasculature and focal pathology.

Bacillary angiomatosis presenting as a soft-tissue tumor without skin involvement.

A patient with human immunodeficiency virus infection presented with a soft-tissue mass which histologically and clinically mimicked an angiosarcoma. Ultrastructural study, however, revealed bacteria identical to those seen in cutaneous bacillary angiomatosis, but the patient had no skin lesions. To our knowledge, this represents the first report of soft tissue involvement by bacillary angiomatosis without the presence of skin lesions.