Biochemical and cytologic analysis of cystic contents in benign non-parasitic symptomatic hepatic cysts before and after ethanol sclerotherapy.

PURPOSE: To examine the fluid of liver cysts by cytologic and biochemical analysis before and after ethanol sclerotherapy in order to explore the etiology of cystic fluid reproduction after sclerotherapy. MATERIAL AND METHODS: The contents of 11 cysts in 11 patients were examined on the day of sclerotherapy, and 2-8 (mean 4.5) days later, and analysed for cytologic and biochemical parameters. RESULTS: Cytologic signs of acute or subacute inflammatory reaction were absent before and present in all cysts after sclerotherapy. Biochemical parameters reflecting the acute inflammatory reaction (CRP, orosomucoid and haptoglobine), changes in capillary permeability (protein, albumin), and the cystic epithelial function (bilirubin, alkaline phosphatase) were significantly elevated after sclerotherapy. CONCLUSION: The post-sclerotherapy fluid production is probably due to an inflammatory reaction. This may explain the success of performing sclerotherapy in one single session.

Pulmonary embolism and heart disease. An autopsy study.

The frequency of pulmonary embolism in patients with myocardial infarction (MI) and chronic rheumatic heart disease (RHE) has been investigated in an autopsy series. The series comprised 21530 hospital autopsies from 1960 to 1984. Altogether 5351 patients with MI and 289 patients with RHE as underlying death cause were selected for this study. Patients with RHE or old myocardial infarction (OMI) had a significantly higher frequency of pulmonary embolism than patients with acute myocardial infarction (AMI) or acute and old myocardial infarction combined (AOMI). This was true irrespective of duration of stay in the hospital during last admission. The frequency of pulmonary embolism decreased in patients with OMI or RHE from 1960 to 1984 suggestive of better therapy of chronic heart failure. A similar trend was seen in patients with AMI during a period with consistent anticoagulation treatment.

Cerebrovascular disease at autopsy and in the death statistics for the county of Hordaland, Norway.

Between 1975 and 1984 a decrease in deaths from cerebrovascular disorders was found both at autopsy and in the official mortality statistics. In the autopsy material (662 cases) the decrease was seen mainly in patients dying of cerebral hemorrhage. Concordance between autopsy and mortality statistics was best in the 30 to 79-year age group. Discordance rose with age, being highest in those above 80 years. This was mainly due to use of the diagnosis "undetermined vascular lesion" given as the clinical cause of death. The diagnosis was not upheld at autopsy. In such cases the presence of a cerebral lesion was rarely confirmed at autopsy. The decrease in acute cerebrovascular deaths was not accompanied by an increase in the number of patients in the category "stroke with sequelae", assessed as a fall in number. Thus mortality statistics can be directly misleading in geriatric patients; and the autopsy frequency in this age group is too low to give a satisfactory picture of events.

Frequency of pulmonary embolism in patients with circulatory disturbances of the lower limb or intestine. An autopsy study.

The frequency of pulmonary embolism in patients with circulatory disturbances in the lower limbs (CDLL) or intestine (CDI) were investigated in an autopsy series. Pulmonary embolism was seen more frequently in patients with CDLL than in patients with CDI. This difference was maintained irrespective of duration of last admission. Patients with CDLL had pulmonary embolism in 36% of the cases when they stayed in the hospital for more than 5 days prior to death, versus 12% in CDI patients. Pulmonary embolism occurred with approximately equal frequency in all age-groups. Surgery had little influence on the occurrence of pulmonary embolism in patients with CDLL. In 85% of the CDLL cases, pulmonary embolism (n = 81) was considered the immediate cause of death at autopsy. The awareness of this life-threatening disease is poor as only 12% had been diagnosed prior to death.

Periodicity in metastatic tumour growth demonstrated in the human liver at autopsy. Preliminary report.

The present study is based on 1,069 autopsies made up of stomach, breast, renal and colonic cancer. Periodicity is described in the liver weight index (liver weight/body height) at death in patients with liver metastases. The seasonal variation tended to be more marked in females and among older patients, and it differed with tumour type. A period with maximum deaths tended to follow that of maximum liver weight index. A periodic difference previously reported in a small series of malignant melanomas is thus not an isolated phenomenon. This indicates that basic biological pathways concerned with the control of tumour growth may be involved. How the system works remains an open question.

Clinically undiagnosed malignant tumours found at autopsy.

In a series of over 20,000 autopsies carried out over a 25-year period, 700 cancers (11%) were found in patients in whom the diagnosis of cancer had not been considered relevant clinically. In over half of them the unrecognized tumour was considered an incidential finding and thus of no importance to the individual concerned, though of epidemiological concern. As expected from the literature the main organs involved were kidney and prostate, with stomach cancer in third place. In contrast, the unrecognized cancers that caused death were most often from the pancreas or lung, again with the stomach in third place. These patients with stomach or lung cancer were frequently thought to have died of other diseases in the gastrointestinal/respiratory tract, and the disease cited was often present though not the cause of death. These patients tended to be older than those with clinically recognized disease, and had been hospitalized late in the course of their fatal illness, at which time clinical recognition would not have influenced the outcome. Earlier recognition of this type of cancer is thus essential. This cannot be achieved without definition and further analysis of the entities concerned.

Trends in cardiac metastasis.

A review of 8571 autopsies disclosed 2833 patients with malignant tumours from 1975 to 1984 at the Department of Pathology, The Gade Institute. Cardiac metastases were found in 130 cases. An increase of cardiac involvement was shown in the autopsy material from 1.2% in 1975-1979 to 1.8% in 1980-1984. The same trend was seen if cardiac metastases were related to malignant tumours. Numerically, lung cancer accounted for most of the metastases seen, but the increase was made up by other tumours than lung cancer. especially malignant melanoma, mesothelioma, breast cancer and sarcomas. These tumours have a high frequency of heart metastases and the increased incidence of these cancers in the material explains the rise of cardiac metastases. Cardiac metastases increased with rising number of distant metastases. This study shows that mesotheliomas have the highest percentage of cardiac spread. The importance of autopsy for detecting metastatic spread in sites that are difficult to detect clinically is emphasized.

Prevalence of pulmonary embolism at necropsy in patients with cancer.

The series studied comprised 6197 patients who had died of or who had cancer at death and represents all patients with cancer from 21,530 necropsies performed at this department from 1960-84. Pulmonary embolism was significantly more common among cancer patients than in those with non-neoplastic diseases. Among those palliatively treated, patients with ovarian cancer, cancer of the extrahepatic bile duct system, and cancer of the stomach had the highest prevalence of pulmonary embolism (34.6%, 31.7%, and 15.2%, respectively). Necropsy patients with cancer of the oesophagus and larynx, together with leukaemia, myelomatosis, and malignant lymphoma had the lowest prevalence (0-5.6%). Palliatively treated cancers in organs of the peritoneal cavity had a significantly higher incidence than all other cancers combined. Cancer of the peritoneal cavity may impede venous drainage from the lower limbs and thus be an important factor in the onset of deep calf vein thrombosis and pulmonary embolism. It is concluded that cancer represents an increased risk factor for onset of pulmonary embolism, in particular in patients with ovarian cancer and cancer of the extrahepatic bile duct system.

Comparison of clinical and postmortem diagnosis of pulmonary embolism.

The incidence of pulmonary embolism and the number of clinically missed diagnoses of it in necropsies carried out between 1960 and 1984 at this department were investigated. Pulmonary embolism primarily affects elderly people with serious underlying disease; in this study it was found more often in women. The incidence of pulmonary embolism (9% of all necropsies) was unchanged during the period studied. In contrast, pulmonary embolism as the "sole" cause of death increased (p less than 0.0005). Although most pulmonary emboli were the immediate cause of death, the clinical diagnosis was often missed (in 84% of all cases). Furthermore, such clinically missed diagnoses increased over the years (p less than 0.005), especially in patients with heart disease and cancer. Without necropsy there will be considerable underdiagnosis of pulmonary embolism, therefore providing a misleading figure in the death statistics for this often fatal disease.

Changes in the cancer spectrum at autopsy: 1975-1984.

In an autopsy series of 8571 cases from 1975 to 1984, cancer deaths increased significantly, particularly in those cases over 60 years of age. A similar trend was seen in the mortality statistics from the district. Study of the degree of correlation between the frequency for the different types of cancer and the total deaths from that cancer at autopsy in the population supplies guidelines for use in assessing the relevance of autopsy findings to epidemiological research. It is stressed that without autopsy control monitoring of cancer in a population is incomplete and unreliable. An autopsy frequency of 40 per cent or more for the cancer in question in the population as a whole is required combined with series of 5-600 cases if satisfactory studies are to be initiated. Such conditions are difficult to fulfil for the less common types, but offer a valid approach to the monitoring of those types of cancer that are numerous enough to merit such attention.

Death certification: increased clinical confidence in diagnosis and lack of interest in confirmation by necropsy is not justified.

Comparison of 742 necropsies from 1975 with 833 from 1984 showed that the degree of certainty the clinicians attached to their diagnosis of the underlying cause of death had increased significantly in 1984. This was due almost exclusively to an increase in the certainty of the diagnosis of circulatory disease. Unfortunately, this was not justified as the numbers of false positive and false negative diagnoses were high in both years. With this increased certainty came a lack of interest in the necropsy. Similar lack of interest was also shown by surgeons in 1984, though in this instance it was accompanied by a high level of agreement between their diagnoses and necropsy findings.

Changes in autopsy profile--1975 and 1984.

In 1975 diseases of the circulatory system were the major cause of death in our hospital autopsies, with neoplasia a poor second. In 1984 the situation was the reverse. The reduction in diseases of the circulatory system was due mainly to that in cerebrovascular cases, deaths from coronary artery disease being unchanged. The increase in neoplasia affected older women in particular, who died from less common types of cancer. It is suggested that these patients may have escaped death from cerebrovascular disease and avoided cancers that usually kill in middle age, to die later of other age-related types that were less common in 1975. The present findings emphasize the importance of recognizing and adjusting to a changing spectrum of disease that is developing in the ageing population found in a West European country.