Cesarean scar pregnancy and early placenta accreta share common histology.

OBJECTIVE: To determine, by evaluation of histological slides, images and descriptions of early (second-trimester) placenta accreta (EPA) and placental implantation in cases of Cesarean scar pregnancy (CSP), whether these are pathologically indistinguishable and whether they both represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester. METHODS: The database of a previously published review of CSP and EPA was used to identify articles with histopathological descriptions and electronic images for pathological review. When possible, microscopic slides and/or paraffin blocks were obtained from the original researchers. We also included from our own institutions cases of CSP and EPA for which pathology specimens were available. Two pathologists examined all the material independently and, blinded to each other's findings, provided a pathological diagnosis based on microscopic appearance. Interobserver agreement in diagnosis was determined. RESULTS: Forty articles were identified, which included 31 cases of CSP and 13 cases of EPA containing histopathological descriptions and/or images of the pathology. We additionally included six cases of CSP and eight cases of EPA from our own institutions, giving a total of 58 cases available for histological evaluation (37 CSP and 21 EPA) containing clear definitions of morbidly adherent placenta. In the 29 cases for which images/slides were available for histopathological evaluation, both pathologists attested to the various degrees of myometrial and/or scar tissue invasion by placental villi with scant or no intervening decidua, consistent with the classic definition of morbidly adherent placenta. Based on the reviewed material, cases with a diagnosis of EPA and those with a diagnosis of CSP showed identical histopathological features. Interobserver correlation was high (kappa = 0.93). CONCLUSIONS: EPA and placental implantation in CSP are histopathologically indistinguishable and may represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

Pregnancy-related thrombosis in a woman with congenital afibrinogenemia: a report of two successful pregnancies.

We managed two pregnancies in a woman with congenital afibrinogenemia with increasing amounts of cryoprecipitate to achieve a pre-infusion fibrinogen level of 60 mg/dL. The first pregnancy resulted in placental abruption at 36 weeks, in spite of recent cryoprecipitate infusion. Both placentas showed infarction. Post-partum ovarian and renal vein thromboses complicated the second pregnancy. Mean FVIII (344%) and vWF Antigen (323%) were elevated prior to cryoprecipitate infusion, with mean post-infusion levels of 367% and 363%. The clearance of fibrinogen after cryoprecipitate infusion increased during the course of pregnancy. A paradoxical prothrombotic state with embolization may play a role in the observed complications of pregnancy.

Prevalence and pathogenesis of pancreatic acinar tissue at the gastroesophageal junction in children and young adults.

BACKGROUND: Pancreatic acinar tissue (PAT) at the gastroesophageal junction (GEJ) has been reported in 3% of adults with Barrett esophagus (BE) and in 24% of healthy subjects. The pathogenesis of this ectopic tissue is controversial. Both an acquired metaplastic process in the setting of BE and a congenital abnormality have been suggested in adults. OBJECTIVE: To clarify the origin of PAT at the GEJ. METHODS: We reviewed material obtained from the GEJ in 69 children and young adults. Each specimen was evaluated by 3 levels stained with hematoxylin-eosin for the presence of PAT, BE, esophagitis, and gastritis. Selected cases were also examined with immunohistochemical stains for lipase, trypsin, and amylase. RESULTS: In 16% of the study population, PAT was present at the GEJ and was not associated with BE. The prevalence of esophagitis and/or gastritis did not vary significantly between patients with and without PAT. CONCLUSIONS: Our data suggest that PAT at the GEJ develops independently of inflammation and is, therefore, likely to be congenital.

Uterine myxoid leiomyosarcoma within a leiomyoma.

A case of myxoid leiomyosarcoma of the uterus arising in a leiomyoma is reported. Although the tumor showed very low mitotic activity ranging from zero to 2/10 HPF, the presence of infiltrative pattern of growth and a high MIB-1 index (60% of cells positive) established the diagnosis. Myxoid leiomyosarcoma may arise in leiomyoma.

Efficacy of Directigen RSV testing in patient management following admission from a paediatric emergency department.

We investigated the use of the Directigen Respiratory Syncytial Virus test performed under 'Stat Laboratory' conditions, in the management of infants after admission from the Paediatric Emergency Department (ED). The study group consisted of 242 consecutive paediatric ED patients tested by Directigen in the Stat laboratory during the winter 1995-1996 respiratory virus season. Specimens were submitted to the Virology Laboratory for confirmatory consensus testing utilizing in part, an in-house multiplex immunofluorescence assay (IFA) and conventional virus isolation methodologies. The sensitivity, specificity, positive and negative predictive values for Directigen, IFA, and isolation, were 71, 91, 85, 80%; 98, 100, 100, 99%; and 51, 100, 100, 72% respectively. Re-testing of 17 discordant original NP aspirates using Directigen, suggested that errors were due to technologist interpretation as well as to overt assay failure. The low analytical sensitivity and specificity of Directigen precludes its use in the clinical setting described in this study. Evening or weekend specimen collection, followed by IFA testing in a centralized Virology Laboratory at the start of the next working day, produces reliable test results. Among the small number of pediatric patients who might be candidates for antiviral therapy IFA testing should be made available on an on-call basis by Virology Laboratory.

Synchronous Paget's disease of the vulva and breast.

We report the first case of synchronous Paget's disease of the vulva and breast diagnosed within a period of 7 months. This is the fourth case of mammary Paget's disease associated with either preceding or following vulvar Paget's disease documented in the literature. With consideration of increasing age of the population, and the fact that vulvar Paget's disease affects elderly women and that breast cancer is the most common malignancy of women in the United States, one can anticipate the occurrence of these two conditions to be more prevalent in the future.

Nodular neuronal hyperplasia: a distinct morphologic type of pseudopolyp in inflammatory bowel disease.

Pseudopolyps constitute a relatively common finding in inflammatory bowel disease and have well-defined microscopic appearances. We report a new, unusual morphologic feature of colonic pseudopolyps in a patient with Crohn's disease, nodular neuronal hyperplasia.