Mistakes on EUS staging of colorectal carcinoma: error in interpretation or deception from innate pathologic features?

BACKGROUND: Because endoscopic ultrasound (EUS) accuracy for staging gastrointestinal tract tumors is limited by many factors, this study was designed to analyze potential sources of error in the EUS staging of colorectal carcinoma. METHODS: All patients referred for EUS evaluation of colorectal carcinoma were staged prospectively by one ultrasonographer and retrospectively by two others with EUS videotape recordings. Pathologic staging was done independently in a blinded fashion. Deceptive pathologic features were defined for T staging by presence of inflammation extending beyond tumor or microscopic spread without inflammation extending to a level consistent with the next stage, and for N staging by large (> or = 10 mm) benign lymph nodes or small (< 10 mm) malignant lymph nodes. RESULTS: Of 22 patients entered into the study, an inflammatory reaction around microscopic tumor spread thought to actually enhance detection by EUS was present in 57.1% of cases. Nine deceptive pathologic lesions were present in 36.4% (8 of 22) of patients (5 T stage, 4 N stage lesions). Of 40 T and N stage mistakes made by the three physicians, 45% were made in the presence and 55% in the absence of deceptive pathologic lesions. Accuracy increased significantly from the presence to absence of deceptive pathologic lesions, from 53.3% to 83.7% (p = 0.029) for T stage, and 8.3% to 73. 1% for N stage (p = 0.0001). Confidence of T staging correlated significantly with accuracy, increasing from 63.3% when unsure to 88. 2% with staging certainty (p = 0.017), an effect not seen for N staging. CONCLUSIONS: Inflammation and desmoplasia around colorectal carcinoma are often present, but may actually enhance EUS detection of microscopic tumor spread. Deceptive pathologic lesions are present in only one third of patients, but account for almost half (45%) of the errors in T and N staging by EUS. Diagnostic accuracy for EUS was increased with confidence in T stage assessment (but not N stage) and in the absence of deceptive pathologic lesions. Errors in interpretation still accounted for the majority of mistakes (55%) made in EUS staging of colorectal carcinoma.

Gestational herpes simplex virus hepatitis.

Hepatitis due to herpes simplex virus (HSV) is unusual in healthy individuals. To date, only 56 cases of HSV hepatitis in adult patients have been reported, including 21 pregnant patients. We describe a 25-year-old white woman in her 30th week of gestation who had progressive acute hepatitis. Histologic examination of the liver biopsy specimen showed diffuse microabscesses involving more than 50% of the hepatic parenchyma, with multiple hepatocytes containing Cowdry type A and ground-glass nuclear inclusions. The diagnosis of herpes hepatitis was confirmed by positive immunoreactivity to HSV antibodies in the tissue sections. Intravenous acyclovir therapy was immediately initiated, and the patient's condition improved dramatically. She then had a normal baby at term. Subsequently, the patient had a second pregnancy and an uncomplicated vaginal delivery without recurrence of the disease. Even though alterations of the humoral and cell-mediated immunity occur during pregnancy, herpes hepatitis is rare in pregnant women. Since the prompt administration of antiviral drugs is a lifesaving measure, we recommend including HSV hepatitis in the differential diagnosis of acute hepatitis in pregnancy.

Cognitive therapy with adolescents.

Cognitive immaturity and distortion are frequently observed in normal adolescents, as well as those with severe psychiatric and behavioral disorders. Misunderstandings of the therapy process and an unstable therapeutic alliance often complicates treatment. Cognitive therapy provides a paradigm for therapeutic intervention and management of therapeutic-alliance problems with adolescents.

A modification of the tannic acid-phosphomolybdic acid-dye stain for demonstrating myoepithelial cells in formalin fixed tissue.

A modified tannic acid-phosphomolybdic acid-dye procedure is used for staining myoepithelial cells in formalin fixed surgical and autopsy material. Paraffin sections are brought to water, mordanted for 1 hr in Bouin's fixative previously heated to 56 C, cooled while still in Bouin's, rinsed in tap water until sections are colorless, rinsed in distilled water, treated with 5% aqueous tannic acid 5-20 min, rinsed in distilled water 30 sec or less, treated with 1% aqueous phosphomolybdic acid 10-15 min, rinsed 30 sec in distilled water, rinsed in methanol, stained 1 hr in a saturated solution of amido black or phloxine B in 9:1 methanol:acetic acid, rinsed in 9:1 methanol:acetic acid, dehydrated, cleared and mounted. Myoepithelial cells of sweat, lacrimal, salivary, bronchial, and mammary glands are blue-green with amido black or pink with phloxine B. Fine processes of myoepithelial cells are well delineated. Background staining is minimal and the procedure is highly reproducible.

Desmoplastic melanoma of the anus.

To date a desmoplastic melanoma, an unusual variant of malignant melanoma, has been described only in the skin. The present report describes a case of desmoplastic melanoma that arose in the anal canal. The patient was without evidence of recurrence or metastases 18 months after surgical removal of the lesion.

Enhancement of the local inflammatory response to bacterial infection by muramyl dipeptide.

The effect of the synthetic immuno-adjuvant compound, muramyl dipeptide (MDP), upon the local inflammatory response to experimental bacterial infection was assessed by histological examination. Within 24 h of the insertion of a bacteria-laden suture into the medial thigh musculature of mice treated with either MDP or placebo, an enhanced degree of polymorphonuclear leucocyte infiltration in the muscle around the suture was observed in the MDP-treated animals. The inflammatory response around a sterile suture was less intense in both treatment groups and specific correlation between the degree of local inflammation and the extent of bacteraemia developing in either group of animals was not noted. The extent of bacteraemia developing in either group of animals was not noted. The previously observed protection conferred by MDP against the local impact of bacterial challenge appears to be mediated in part by enhancement of the acute local inflammatory response.

Treatment of tardive dyskinesia with propranolol.

A double-blind, intensive case design was used to study the effect of propranolol on tardive dyskinesia. No short-term improvement was observed, but two of the four subjects responded to long-term propranolol use. Properties of propranolol other than acute beta blockade are suggested as possible mechanisms of action.

Cholesterol granulomas of the breast. A lesion which clinically mimics carcinoma.

Cholesterol granuloma formation is an unusual development in the advanced stage of mammary duct ectasia. Its recognition is important because it can be clinically, mammographically, and grossly confused with carcinoma. Five such cases thought clinically to be carcinoma are presented. The histologic findings in cholesterol granuloma are distinctive and consist of multiple cholesterol crystals arranged either singly or in tightly-packed arrays. Foreign body giant cells surrounding the cholesterol deposits are invariably present.

Giant adrenal myelolipoma: case report and review of the literature.

Adrenal myelolipomas are rare tumors that consist of mature fat and bone-marrow elements. The majority that have been reported are small, asymptomatic lesions incidentally observed at the time of autopsy. In recent years, larger, symptomatic myelolipomas have been successfully resected. We studied the case of a giant adrenal myelolipoma in a 70-year-old woman. She was obese, hypertensive, and had abdominal pain, findings frequently associated with these lesions. Unusual features included formation of prominent bony spicules, a 52-year history of an abdominal mass, and massive size (5,500 g). To our knowledge, it is the largest myelolipoma yet reported.

Endometriosis of the male urinary system: a case report.

Tissue histologically indistinguishable from endometrium was removed from the bladder of a 73-year-old man. The lesional tissue involved the right ureterovesical junction, producing hydronephrosis on the right side. The patient had an adenocarcinoma of the prostate and had been on estrogen therapy for 5 years before diagnosis of endometriosis. Two previous reports of endometriosis in male subjects, who were also on estrogen therapy, are reviewed briefly.

Evidence for a structural relationship between successive parallel tubules in the SR network and supernumerary striations of Z line material in purkinje fibers of the chicken, sheep, dog and rhesus monkey heart.

The striations and the intervening filaments observed in the present study have been variously designated in the literature as: prodomal pattern, leptomeric myofibril, microladder, leptomeric organelle, leptofibril and zebra body. Electron microscope examinations of Purkinje fibers from the septa, papillaries, trabeculae carneae and small endocardial strands from chicken, sheep, dog and monkey hearts have revealed a close association between densely stained striations of supernumerary Z line material and successive parallel tubules in the network formed by the sarcoplasmic reticulum (SR). The striations appear to be linked together by filaments that somewhat resemble the part of thin filaments attached to Z lines in normal fibrils. The evidence for a close association of striations and SR tubules is derived from a similarity of spacing between striations and successive parallel tubules in the SR network and from a resemblance of striation and SR network patterns. The evidence for a structural relationship between striations and SR tubules is derived from the observation of electron-opaque strands traversing the space between striations and SR tubules.

Relationship of the sarcoplasmic reticulum to fibril and triadic junction development in skeletal muscle fibers of fetal monkeys and humans.

Examinations of stages of fibril development in muscle fibers of seven Rhesus monkey and six human fetuses reveal SR tubules encircling the Z lines at all stages of fibril development. The encircling SR tubules are continuous with the SR network of tubules which is found surrounding fibrils at all stages of development observed. The SR tubules encircling the Z lines show connections (electron-opaque strands) with the Z lines. The developing triadic junction shows a progressive increase in complexity of structures within the junction. First, membranes of T and SR become apposed with no visible structure between them- Second, tenuous connections are found traversing the space between apposed membranes. Third, well developed bridges are seen traversing the space. And finally, an intermediate density midway between the apposed membranes and parallel to them is found in favorable sections. Junctions between T tubule membranes were also observed and the structures in these junctions are somewhat similar to those found in junctions between T and SR membranes. The change in orientation of triads from predominantly longitudinal to predominantly transverse is complete in the 18-week monkey fetus and incomplete in the latest stage (28-week) of fetal development observed in humans.

Development of the triadic junction in skeletal muscle fibers of fetal and postnatal rats.

Electron microscope examinations of the developing triadic junction in fibers from leg muscles of fetal and postnatal rats reveal a range of complexity from no structural connections across the space between apposed membranes of T and SR to all of the junctional structures visible in adult rat muscle fibers. In triads showing no connections, faintly stained projections from the apposed membranes of T and SR are seen. The simplest form of junctional structure is a series of faintly stained strands that make connections across the space between apposing membranes. Junctional structures stained more intensely show periodic bridges traversing the space plus an intermediate dense line (intermediate density) running parallel to the apposed membranes of T and SR and bisecting the space between apposed membranes. The intermediate density is continuous across the periodic bridges and interbridge spaces and it appears to be connected to the apposed membranes of T and SR. It is suggested that projections from T and SR are precursors of the connections and that the projections interact to form the intermediate density. It is also suggested that bridge and interbridge junctional structures might form compartments isolated from the sarcoplasm and thus enhance the flow of electrical current from T to apposed SR by reducing low-resistance shunting of current flow into the sarcoplasm,

Topical 5-fluorouracil treatment of superficial basal cell epithelioma. A light and electron microscopic study.

A 27-year-old patient developed superficial basal cell epitheliomas approximately 20 years after taking Fowler's solution. One of the lesions was successfully treated with topical 2% 5-fluorouracil soultion under occlusion. Sequential biopsies of the lesion before, during and after therapy were examined by light and electron microscopy, and the changes at various stages are described. Changes occurred only in tumor cells and adjacent epidermis, and only after occlusion of 5-FU. After one week of occlusive therapy, focal discontinuities in the basal lamina and intercellular spaces were wider with reduction and condensation of tonofilaments. Mitochondrial degeneration was seen along with irregularities in nucleoli. These changes were most prominent after two weeks of occlusive therapy, and many degenerating keratinocytes were seen detached from other cells. One month after cessation of therapy, the entire area was excised, and no evidence of tumor was seen.

Ultrastructure of sclerosing hemangioma.

Specimens from 9 patients with the varying histopathologic patterns of sclerosing hemangioma were studied by electron microscopy. Not only were there numerous identifiable vascular spaces, but many of the cells had the ultrastructural characteristics of endothelial cells whether they were lining vascular spaces, forming organoid structures or were isolated. The Weibel-Palade bodies served as a marker for endothelial cells. They are rod-shaped, with a length up to 2 mu and a diameter up to .1 mu, and contain a tubular substructure, the diameter of the individual tubules being 150 [unk]. Our findings clearly support Gross and Wolbach's theory that this group of lesions is of endothelial origin.