Pathology of benign and malignant breast disorders.

An understanding of the basic anatomy and pathology of the breast is necessary for optimal interpretation of breast imaging studies. This article discusses the normal anatomy and the pathology of benign, high-risk, and malignant lesions of the breast.

The second annular pulley: a histologic examination.

The second annular pulley and underlying flexor tendons from 15 fresh frozen fingers were prepared, sectioned transversely and longitudinally and then stained with hematoxylin-eosin, Verhoeff-Van Gieson (Elastin), Masson's trichrome and for the presence of hyaluronic acid. Three discrete layers of the second annular pulley were identified (1) an outer layer, continuous with the membranous sheath, that was richly vascularized; (2) a middle layer, characterized by radially oriented collagen fibrils and significant elastin fibrils; (3) an inner gliding surface, characterized by longitudinally oriented collagen fibrils and modified fibroblasts secreting hyaluronic acid. The three layers of the pulley seem specialized and have developed based on the functional requirements of the pulley apparatus. The outer layer serves as a source of vascular supply and nutrition, the middle layer maintains structural integrity and is organized to efficiently resist flexor tendon bowstringing, and the innermost layer facilitates efficient excursion of the underlying flexor tendons both by the orientation of the collagen fibers and by the secretion of substances that are thought to minimize friction.

Persistent and recurrent sporadic primary hyperparathyroidism: histopathology, complications, and results of reoperation.

BACKGROUND: Our purpose was to analyze the causes of persistent and recurrent sporadic primary hyperparathyroidism (PD and RD). METHODS: The histopathology, complications, and results of reoperation were studied. Five hundred sixty-eight patients with primary hyperparathyroidism were operated on initially by one surgeon and underwent follow-up examination for 3.7 +/- 3.8 years. During the operation, all parathyroids were sought and confirmed by biopsy. Enlarged glands were resected, and subtotal parathyroidectomy was done for multiglandular disease (hyperplasia). RESULTS: The cure rate after the initial surgical procedure was 96.4%, PD = 2.8% (16 of 568). At reoperation (10 of 16), nine of 10 were cured (90%) (two adenomas, six hyperplasias, one lung carcinoma). RD was documented (at years 4, 4, 10, 15, 16) in five (0.9%) patients, one with parathyroid carcinoma and four with hyperplasia. Thirty-five patients with PD and two patients with RD were referred for reoperation: 17 with adenomas (eight mediastinal) and 18 with hyperplasias (one mediastinal gland). Preoperative calcium level was higher for PD (12.57 mg/dl) and RD (13.89 mg/dl) versus all cases (12.19 mg/dl) (p < 0.03 and p < 0.0005, respectively). After reoperation, normocalcemia was achieved in 47 (92.%) of 51 patients with PD or RD. Transient hypocalcemia occurred in 22% of patients (permanent, 2.0%) and transient hoarseness in 2.0% of patients (no permanent nerve damage). Permanent hypocalcemia and nerve damage after 568 initial operations were 0% and 0%, respectively. Two perioperative deaths occurred. CONCLUSIONS: We conclude that inadequate neck exploration or resection of hyperplastic tissue accounts for most cases of PD and RD. Optimal results necessitate intraoperative identification of all parathyroids whenever possible, with minimal morbidity.

Large cell carcinoma of the lung: a highly aggressive tumor with dismal prognosis.

A retrospective review was made of 96 consecutive patients with large cell carcinoma of the lung admitted to Emory University Hospital over 10 years. Only 10 patients were seen with stage I lesions favorable for resection. The remainder were treated primarily with irradiation or chemotherapy. Mean survival for clinical stage I patients was 15.9 months; stage IIIA patients, 7.9 months; stage IIIB patients, 7.1 months; and stage IV patients, 5.8 months. Only 1 patient survived for 5 years. This distinct and highly aggressive form of lung cancer most commonly is seen at an advanced stage and is associated with an unusually dismal prognosis regardless of the method of treatment employed.

Carcinomatous involvement of the thyroid presenting as subacute thyroiditis.

Carcinomatous involvement of the thyroid is a most unusual cause of hyperthyroidism and thyroiditis, with only a few cases reported in the literature. The authors present a 35-year-old woman with signs, symptoms, and laboratory findings of hyperthyroidism, and subacute thyroiditis that was due to extensive replacement of the thyroid gland by adenocarcinoma (shown by fine needle aspiration). After chemotherapy with vincristine and cisplatin, the swelling of the thyroid resolved, thyroidal uptake of radioactive iodine increased, and mild hypothyroidism developed. Despite the improvement in her thyroid status, she died from progressive malignancy. This case illustrates the value of fine needle aspiration cytology where doubt exists in the diagnosis of thyroid disorders.

Zygomycosis presenting as nasal polyps in a healthy child.

A 15-year-old boy presented with unilateral nasal polyps. Pathological examination showed submucosal granulomas and fungal organisms with occasionally septate hyphae. These organisms were identified by the Centers for Disease Control, Atlanta, as being members of the class of fungi known as Zygomycetes (formerly Phycomycetes). Based on strong morphological and clinical criteria, we believe the causative organism to be Entomophthora coronata. The patient had no evidence of diabetes mellitus or compromised immunity. This patient represents an unusual case of nasal polyps caused by an organism that has rarely been diagnosed in North America.

Imaging guided percutaneous hepatic biopsy: diagnostic accuracy and safety.

During the 3-year period from May 1981 to June 1984, 145 patients with hepatic abnormalities demonstrated by computed tomography (CT) or ultrasonography (US) underwent 151 imaging guided percutaneous hepatic biopsies. These biopsies were performed with needles ranging in size from 21-gauge aspiration to 14-gauge cutting type. Histologic and cytologic results were correlated with subsequent surgical, autopsy, and clinical follow-ups ranging from 2 months to 3 years. The overall accuracy for imaging-guided biopsies was 92.1% and 98% for diagnosis of malignant lesions. Our complication rate of 1.3% is comparable to that reported in other studies. We discuss indications, techniques, and risks for imaging-guided percutaneous hepatic biopsy.

Percutaneous biopsy of pancreatic masses.

Forty-five percutaneous needle biopsies of pancreatic masses were performed in 41 patients in whom there was clinical or radiological concern for the diagnosis of cancer. Computed tomography (CT) was the imaging technique used in 41 of the 45 biopsies. An overall sensitivity of 85%, specificity of 100%, and accuracy rate of 88% were achieved, with serious complications in three of the 45 attempts (6.7%). These figures show that percutaneous pancreatic biopsies have the potential for greater accuracy than has been previously reported and are relatively safe when compared with surgery.

Bilateral clear cell papillary cystadenoma of the epididymides presenting as infertility: an early manifestation of von Hippel-Lindau's syndrome.

Papillary cystadenoma of the epididymis is a rare benign tumor, accounting for only 4 per cent of all epididymal tumors. Histologically, it can be confused with metastatic renal cell carcinoma. We report a case of bilateral involvement of the epididymides and infertility. Its diagnostic significance is its association with the von Hippel-Lindau syndrome, necessitating close surveillance.

CT-guided adrenal biopsy: accuracy, safety, and indications.

Fifty-eight percutaneous needle biopsies of adrenal masses were performed in 53 patients. The technique was initially successful in 44 (83%) of 53 patients. Five patients had second procedures because of initial failure or the possibility of sampling error. Fourteen biopsies were performed in nononcologic patients and 39 in patients with a known malignancy. None of the adrenal masses in nononcologic patients were malignant. Only 18 (46.1%) of the 39 masses in oncologic patients were metastases; the rest represented a variety of nonneoplastic conditions. Seven minor complications occurred in six patients. Two of these patients required transfusions for hypotension or decreases in hematocrit. No correlation was noted between needle size and complications. There were no pneumothoraces. The procedure is an accurate and safe alternative to surgical biopsy.

Approach to the spectrum of Budd-Chiari syndrome: which patients require portal decompression?

Budd-Chiari syndrome (occlusion of the hepatic veins) represents a spectrum disorder. From 1974 to 1984, 20 patients with the syndrome were managed. Eleven required shunt surgery (Group 1) and 5 were managed with nonshunt therapy (Groups 2 and 3). Results have been good. Retrospective review of the liver biopsy specimens showed that Group 1 patients had a greater degree of zone 3 necrosis than Group 2 and 3 patients. We submit that presence of zone 3 necrosis on an initial liver biopsy specimen may define the failing liver of Budd-Chiari syndrome that requires conversion of the portal vein to an outflow tract by shunting.

The role of routine biopsy of all parathyroid glands in primary hyperparathyroidism.

Since 1974, a concerted effort has been made to identify and biopsy all parathyroid glands in patients presenting with primary hyperparathyroidism. From 1974 until July 1982, 247 patients had initial cervical exploration for primary hyperparathyroidism. The percentage of patients in whom four or more glands were identified rose from 53 per cent in 1974 to as high as 88 per cent, with a mean of 80 per cent during the 8.5-year period. Ectopic location, prior thyroid surgery, and detrimental effects of prolonging surgery in some patients are reasons precluding localization of all glands in every patient. The percentage of biopsies positive for parathyroid tissue rose from 78 per cent in 1974 to 94 per cent in 1982. Routine biopsy of all glands provided the following results of classification in the 247 cases: adenoma, 56 per cent; diffuse hyperplasia, 18 per cent; nodular hyperplasia, 24 per cent; carcinoma, 0.8 per cent; and in three cases, four normal glands were identified. The one major complication was a case of temporary bilateral recurrent laryngeal nerve palsy. Mean follow-up period is 3 years. There was no case of permanent hypocalcemia and no operative deaths. Persistence and recurrence rates are 4.9 per cent and 0.4 per cent, respectively. Four of the patients with persistence and the one patient with recurrence have required reexploration. All but one of these was considered cured by reoperation. Eight of the 12 patients with initial persistent hypercalcemia postoperatively have been managed conservatively. These results suggest routine attempts to identify and biopsy all glands can be performed with minimal risk and complications and without permanent hypocalcemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital abdominal aortic aneurysms: report of a case and review of the literature.

Congenital abdominal aortic aneurysms are medical curiosities because of their rare occurrence even in groups with hereditary derangements of connective tissue metabolism (e.g., Marfan's syndrome and Ehlers- Danlos syndrome). We present the case of a 2 1/2-year-old boy with a congenital aneurysm of the aortoiliac bifurcation managed by excision and graft replacement. No associated disorder of connective tissue or other pathogenetic mechanism was discovered in this patient. The authors have summarized the existing literature regarding these rare but potentially lethal aneurysms.

The computed tomography-guided adrenal biopsy. An alternative to surgery in adrenal mass diagnosis.

A series of 16 patients with adrenal masses were biopsied percutaneously under computed tomography (CT) guidance with 18- to 22-gauge modified Chiba needles. Adrenal adenomas, cysts, metastases, melanoma, and adrenal hemorrhage were identified. Of nine oncologic patients, four had adrenal metastases, while five had other nonmalignant adrenal masses. Thus, an adrenal mass in an oncologic patient is not always metastases. No complications occurred. The diagnostic evaluation of an adrenal mass in selected cases should include CT-guided percutaneous aspiration as a safe and reliable alternative to open surgical biopsy. CT-guided biopsy can be performed as an outpatient procedure, avoiding the cost of hospitalization and the morbidity of surgery.

Carcinoma of the parathyroid gland: is it overdiagnosed? A report of three cases.

The true incidence of carcinoma of the parathyroid gland is probably about 1 percent of cases of primary hyperparathyroidism. Overreporting may occur if the diagnosis is based on histologic appearances alone because the histologic criteria are less than definitive. Carcinoma of the parathyroid gland, if diagnosed early and treated with adequate surgical excision, is associated with a satisfactory long-term prognosis. However, the possibility of distant metastases or locally recurrent disease is not necessarily excluded by a prolonged interval of disease-free status, and the physician should continue to follow the patient on a regular basis by physical examination and routine serum calcium analysis.

Massive prostatic infarction following aortocoronary bypass surgery: a report of two cases.

We present two patients who had massive prostatic infarctions following coronary bypass surgery. Whereas small areas of prostatic infarction are commonly seen in urologic practice, massive infarction is rarely seen. Massive prostatic infarction has been observed under conditions similar to those occurring with bypass surgery, so no claim is made that the condition occurs uniquely in patients who have recently undergone bypass surgery. Since coronary bypass surgery is commonly performed and since the procedure is often done on men with prostatic hyperplasia, we can reasonably expect to see this condition more commonly that we have in the past. It is our hope that others will be alerted to this condition and look for it in patients with prostatism who undergo coronary bypass surgery, other types of cardiac surgery, and any condition where prostatism and hypotension are present and pressor agents are used in treatment.

Multiple NMR T2 relaxation values in human liver tissue.

Twenty-one human hepatic liver biopsy samples were evaluated by nuclear magnetic resonance spectroscopy. This spectroscopy was performed by obtaining multiple and not single T2 values (T2-long and T2-short). Neoplastic tissue had greater T2-long and T2-short values than diffuse liver disease. The T2-short correlated, r = 0.947 (p less than 0.01), with the percentage of cancer cellularity within the tissue specimens. There was no correlation between the multiple T2 values and the degree of fibrosis and inflammation. Minimal correlation was noted between the T2-long and percentage of fat within the diffuse disease (cirrhotic) specimens, r = 0.636 (p less than 0.05). The possible reasons for the above findings are discussed.

CT directed hepatic biopsies: increased diagnostic accuracy with low patient risk.

A technique for computed tomography directed percutaneous liver biopsy using small gauge (18-20) needles is described. In 51 procedures performed on 50 patients tissue specimens adequate for diagnosis were obtained 49 times (96%). There was one false negative diagnosis. The correct diagnosis was made in 48 of 51 (94%) procedures on 48 of 50 (96%) patients. There were no significant complications.