Hamartomas of the breast: clinical, radiologic, and pathologic manifestations.

Between 1986 and 1996, 35 patients with a diagnosis of hamartoma of the breast were seen at the Mayo Clinic. One patient had two lesions. The mean age was 50 years (range 21-86 years). Hamartomas were clinically identified as a palpable lump in 18 cases (11 were detected by the patient and 7 by a physician). The other 18 were identified mammographically. Twenty-four lesions were in the left breast and 12 were in the right breast; 39% were located in the upper outer quadrant. Mammographically most hamartomas were ovoid, and the lesions were well circumscribed. Sonographically they were all solid, but 24% showed cystic areas. Pathologically the mean greatest diameter was 3.2 cm (range 1.0-7.5 cm). All but one lesion showed circumscription. The mean percentage of fibrous tissue was 78% (range 5-95%), fat 13% (range 0-95%), and epithelium 9% (range 1.0-60%). Calcifications were seen in four lesions. Ductal hyperplasia was present in 27% and adenosis in 70% of lesions. Twelve percent of patients had coexistent fibroadenomas.

Primary localized amyloidosis of the urinary bladder: a case series of 31 patients.

OBJECTIVE: To evaluate the presentation and prognosis of primary localized amyloidosis of the urinary bladder. PATIENTS AND METHODS: The medical records of 31 patients with primary localized amyloidosis of the urinary bladder were reviewed. Immunohistochemical amyloid typing was performed on bladder biopsy specimens from 27 patients. RESULTS: The median age of the 22 men and 9 women was 55 years. Twenty-four patients (77%) presented with gross hematuria (associated with irritative urinary tract symptoms in 6 patients), and 7 (23%) had only irritative lower urinary tract symptoms. Multiple bladder areas were involved in 20 patients (65%), a single area was involved in 8 (26%), and diffuse involvement was present in 3 (10%). Twenty-four patients had immunoglobulin light chain, and 3 had transthyretin-related amyloid. Local recurrences were common. None of the patients developed systemic amyloidosis. CONCLUSION: Primary localized amyloidosis of the urinary bladder can be easily confused with a neoplasm. Immunohistochemical amyloid typing is important. Transthyretin-related amyloid of the bladder requires no further work-up. Repeated work-ups for systemic amyloidosis are unnecessary for patients with light chain-related amyloidosis of the urinary bladder. Early eradication with fulguration or laser therapy is indicated. Cystoscopic follow-up is necessary.

The German Pflegeversicherung (long-term care insurance).

The German Pflegeversicherung, introduced in January 1995, has been very successful. It has been well accepted by persons in need and by their relatives and friends, providing benefits for both parties. The insurance is financially sound and has helped to create new workplaces.

The German health-care system.

The German health-care system is characterized by a statutory health insurance based on the principle of social solidarity. Nonprofit sickness funds and regional associations of physicians are the central components of the German system. The historical development of the system for more than 100 years has been characterized by negotiations, rather than confrontation, among physicians, patients, and insurance carriers. With the increasing sophistication of modern medicine, medical expenditure is rising, and great demands are facing the health-care systems of the industrialized world. The hope is that the German system will be able to preserve the principle of solidarity and remain a one-tier health-care system rather than allow health care to be viewed as essentially a private consumption good, in which case availability and quality are allowed to vary with family income. As a means to achieve this goal, the autonomy of the sickness funds and regional associations of physicians will be increased substantially, and the governmental authority will be decreased. Strengthening of autonomy must be accompanied by incentives for self-responsibility and self-participation of Germany's citizens.

Renal cell carcinoma: diagnosis based on metastatic manifestations.

Renal cell carcinomas are notorious for their tendency to metastasize early, often before the primary tumor has become apparent. Frequently, the initial complaint is referable to a distant metastatic lesion. Metastatic lesions have been found in almost every organ or tissue of the body. When a patient with a clinically asymptomatic renal cell carcinoma has signs and symptoms referable to a localized lesion, the final diagnosis depends on histologic and cytologic evaluation of a biopsy specimen. In this article, we describe a patient who had a pulsating transcalvarial occipital-suboccipital mass as the initial manifestation of an occult renal cell carcinoma. Initial manifestations by site of metastasis described in the literature are reviewed, and the differential diagnosis of primary clear cell tumor versus metastatic lesions from a renal cell carcinoma, according to their pathologic features, is discussed.

Cold spots on bone scans in patients wearing weighted breast prostheses.

A bone scan is frequently obtained in patients with breast cancer for evaluation of possible metastatic bone disease or for evaluation of response of known metastases to treatment. These patients commonly wear breast prostheses after unilateral or bilateral mastectomies. On some bone scans, the authors have observed artifacts resulting from certain breast prostheses. In particular, in the patient described, a weighted breast prosthesis was not removed during Tc-99m HMDP bone scanning and was interpreted as being permanent pacemaker or defibrillation unit. The scintigraphic appearance of several commonly used, commercially available weighted breast prostheses is discussed.

Mu-heavy chain disease: presentation as a benign monoclonal gammopathy.

mu-Heavy chain disease (HCD) is a rare monoclonal lymphoid disorder characterized by the failure to assemble a complete IgM immunoglobulin. The mu-heavy chains analyzed to date revealed absence of the variable region and a shortened constant domain. We report the first case of mu-HCD presenting as a benign monoclonal gammopathy. The literature on the 27 reported mu-HCD cases is reviewed, and important clinical and laboratory findings are discussed. The ages of the patients ranged from 15 to 80 years (median, 57.5 years). Twenty-two of 27 patients had an associated lymphoplasma cell proliferative disorder. A monoclonal spike on routine serum protein electrophoresis was found in only 8 of 19 patients. Fourteen of 22 patients had Bence Jones proteinuria, but mu-HCD protein was reported in the urine of only two patients. The survival ranged from less than 1 month to 11 years (median, 24 months).

Idiopathic thrombocytopenic purpura: detection of accessory splenic tissue.

The presence of Howell-Jolly bodies in the peripheral blood smear does not rule out the possibility that small amounts of splenic tissue are present. The liver-spleen scintigram appears to be the most sensitive test at this time for the detection and localization of functional accessory splenic tissue. Three of seven patients with idiopathic thrombocytopenic purpura and splenectomy had no Howell-Jolly bodies before removal of an accessory spleen. Therefore, the performance of a routine blood smear as the only test appears to be of limited value. Our data and a review of the literature do not allow a definitive statement as to the effectiveness of accessory splenectomy in patients with recurrent idiopathic thrombocytopenic purpura and with accessory splenic tissue. However, until this is clarified, accessory splenectomy should be considered as a possible therapeutic modality.

Cobalt excretion test as index of iron absorption and diagnostic test for iron deficiency.

A cobalt excretion test was performed in 50 patients with various, mainly hematologic, disorders and was found to be an accurate and easily obtainable index of iron absorption. The test was found to be of very limited value in predicting iron stores. The cobalt excretion test may have some usefulness as a simple, apparently safe, noninvasive test for identification of persons with iron depletion resulting from uncomplicated blood loss. However, in more complex circumstances, it fails to differentiate iron deficiency anemia from anemia due to other causes.