Tumors of the salivary glands. Comparison of frozen-section diagnosis with final pathologic diagnosis.

Of the 256 cases of salivary gland tumors subjected to frozen-section diagnosis, the error rate in diagnosis for malignant disease was one of four cases, and in benign disease, it was one of ten cases. Six of the 52 malignant tumors were erroneously labeled as benign, while four of the 204 benign tumors were diagnosed as malignant neoplasms. The occurrence of concurrent benign and malignant disease, nonneoplastic alterations of salivary gland tissue, and sampling errors militated against total reliance on frozen-section diagnosis in the management of salivary gland neoplasms.

Carcinoma of the prostate: clinical and pathological staging and prognosis.

Clinical and pathological staging furnishes valuable information upon which the clinician can base his treatment and compare results. Staging refinements occur as we learn more about the natural history of the disease and the efficacy of our treatment. We observed that clinical stage B patients with minimal (less than twice normal) elevation of the serum acid phosphatase have similar pathologic stage B (75%) and disease-free survival rates following total prostatectomy as stage B patients with normal acid phosphatases. Intraglandular crystalloids were found in 26% of clinical stage B patients treated by total prostatectomy, and none of this subgroup of patients has had a recurrence of disease. Pathologic staging frequently confirms the presence of a greater extent of tumor than was clinically anticipated. In general, prognosis for patients with a small tumor mass will be more favorable than that for patients with a large tumor mass. Staging permits the estimation of prognosis of groups of patients with similar tumor burdens; however, the survival of an individual within any such group is unpredictable.

Acute respiratory distress syndrome after peritoneovenous shunt.

A case is presented in which a fatal acute respiratory distress syndrome, associated with disseminated intravascular coagulation, developed immediately after the insertion of a peritoneovenous shunt for management of refractory ascites. The absence of left-sided heart failure or fluid overload was established by (a) lack of diuresis from intravenous furosemide; (b) repeatedly normal pulmonary wedge pressures; and (c) autopsy findings. The nature of the toxic effect of this patient's ascites upon the alveolar membrane remains obscure.

Cerebral embolism in Libman-Sacks endocarditis.

Left homonymous hemianopia, hemiparesis, left-body clonic seizures, and progressive deterioration of consciousness complicated the clinical course of a 57-year-old woman with systemic lupus erythematosus (SLE). Autopsy documented the presence of multiple brain infarcts and cerebral arterial emboli that originated from the verrucae of Libman-Sacks endocarditis. Clinicians and pathologists should consider this unusual vascular mechanism of cerebral injury in patients with SLE who develop strokes.

Langerhans cells and serum precipitating antibodies against fungal antigens in bronchioloalveolar cell carcinoma: possible association with pulmonary eosinophilic granuloma.

In an ultrastructural study of 37 cases of bronchioloalveolar cell carcinoma (BAC), we identified seven cases (19%) in which Langerhans cells (LC) were closely associated with tumor cells. Serum precipitating antibodies against Aspergillus species and/or thermophilic actinomyces were present in five BAC patients whose tumors contained LC and in six patients whose tumors lacked LC. In a simultaneous study we identified marked atypical bronchiolar and alveolar lining cell hypertrophy and hyperplasma in pulmonary eosinophilic granuloma (PEG). Our data plus current information suggesting that PEG is a form of hypersensitivity pneumonitis support our hypothesis that those cases of BAC in which LC are present may rise in localized or diffuse pulmonary scars caused by PEG.

Electron microscopy in the diagnosis of liposarcoma and fibrosarcoma of the larynx.

Electron microscopy (EM) was useful in establishing the final diagnosis in specific instances of liposarcoma and fibrosarcoma of the larynx. In the first case light microscopy revealed cells that met the histologic criteria of a low grade liposarcoma; EM revealed cells that displayed a varied ultrastructural differentiation; thus the tumor was classified as a mixed mesenchymal tumor rather than liposarcoma per se. In the second case, pathologic evaluation indicated a grade 2 fibrosarcoma. EM revealed malignant mesenchymal cells that closely recapitulated normal fibroblasts (no epithelial differentiation was present). This kind of information enables more accurate determination of the source of the primary lesion than results of light microcsopy alone.

Cytologic, histologic and electron microscopic correlations in poorly differentiated primary lung carcinoma. A study of 43 cases.

For 43 poorly differentiated lung carcinomas we compared cytopathologic diagnoses made on specimens obtained prior to biopsy with histologic and electron microscopic diagnoses. Tissues were obtained by transbronchial biopsy, mediastinoscopy o pulmonary resection. Cytologies, tissues and electron micrographs were reviewed independently and blindly by five pathologists and one cytotechnologist. The cytologic, histologic and electron microscopic diagnoses agreed in 27 cases (62.7%), including adenocarcinoma (12), squamous carcinoma (five), oat cell carcinoma (six), mesothelioma (two) and adenosquamous carcinoma (two). In 14 cases the cytopathologic diagnoses had more accurately reflected the cell type ultimately diagnosed by electron microscopy than had the histologic diagnoses. Of ten poorly differentiated adenocarcinomas, eight had been interpreted as large-cell undifferentiated carcinomas, one as squamous carcinoma and one as poorly differentiated carcinoma histologically. Four poorly differentiated squamous carcinomas had been histologically diagnosed as giant cell, oat cell, undifferentiated carcinoma and adenocarcinoma. In these cases the previous cytologic diagnoses had been in agreement with the ultimate electron microscopic interpretation. The accuracy of cytodiagnoses may exceed that of histologic diagnoses in poorly differentiated lung cancer.

The ultrastructural diagnosis of tumors of the head and neck.

Electron microscopy has proved to be a valuable diagnostic tool in surgical pathology. As shown in three illustrative cases, the procedure is most useful in accurately classifying light microscopically diagnosed undifferentiated tumors of the head and neck, and is also helpful in predicting the origin of cervical lymph node metastasis in occult cancer. It also serves to quality control diagnoses made by light microscopy. All surgical specimens are fixed in a fixative that gives adequate ultrastuctural preservation and allows retrieval and examination by electron microscopy, if indicated. Recent technical improvements have resulted in a turn-around time of less than two days, thus making diagnostic electron microscopy clinically useful. The ultrastructural examination of undifferentiated tumors has a high diagnostic yield, often obviating additional diagnostic procedures and exploratory surgery. The correct diagnosis results in appropriate therapy and accurate assessment of prognosis.

Adenocarcinoma in regional enteritis of the small intestine.

An increased risk for regional enteritis patients of small bowel adenocarcinoma to develop has been suspected but unproved. We have analyzed 49 cases reported since 1957 and two additional ones of our own. These have been compared with a current group of small bowel adenocarcinomas not associated with regional enteritis. The Crohn-associated cancers differed from adenocarcinomas not associated with Crohn disease in that (1) mean age at cancer discovery was less (46 vs 64 years), (2) more cancers arose in the ileum (76% vs 27%), (3) diagnosis and cure were less successful, and (4) they occurred more frequently. The 32 cases reported in the past five years were compared with the expected 0.1 to 5 cases. Regional enteritis patients were found to have an increased risk for the development not only of small bowel adenocarcinoma, but one that is more occult and lethal than that in individuals wihtout Crohn disease.

Role of hormones in growth kinetics of renal cell carcinoma in vitro.

Medroxyprogesterone acetate has been used to treat metastatic renal cell carcinoma largely because of its observed inhibitory effects on the growth of estrogen-induced tumors in male Syrian golden hamsters. The absence to date of any successful, established chemotherapeutic regimen in the management of metastatic renal cell carcinoma has led to the continued application of medroxyprogesterone acetate in the majority of patients with this disease because of the occasional regression witnessed (particularly in male patients) and the absence of untoward side effects. To examine the mechanism of action of medroxyprogesterone acetate renal cell carcinoma tumor cells from a patient who had responded to medroxyprogesterone acetate therapy were established in tissue culture. Cells were cultured in control medium, and in the presence of therapeutic and pharmacologic levels of medroxyprogesterone acetate. Tumor cell growth kinetics were determined by the incorporation of 3H thymidine. There was no growth inhibition effected by medroxyprogesterone acetate at therapeutic or pharmacologic levels. Therefore, the proposed salutary effect of medroxyprogesterone acetate in regression of metastatic renal cell carcinoma results from factors other than direct inhibition of renal cell carcinoma growth.

Granulomatous prostatitis: confusion clinically with carcinoma of the prostate.

Non-specific granulomatous prostatitis is an inflammatory response of a foreign body type to extravasated prostatic fluid. Its significance is incident to its frequent confusion with carcinoma of the prostate. Noteworthy is the rapidity of onset of irritative and obstructive symptoms in a relatively younger age group than one generally sees in carcinoma of the prostate. Tissue diagnosis in those suspected of carcinoma of the prostate should be established by needle biopsy and conservative measures used for at least 4 weeks in the treatment of obstructive symptoms to allow the inflammatory response to subside before intervening surgically . Most patients frequently have associated benign prostatic hyperplasia with persistent obstructive symptoms and significant residual urine. Transurethral resection of the prostate has been performed in this study without postoperative complications.

Random mucosal biopsies in the evaluation of patients with carcinoma of the bladder.

The management of patients with recurrent transitional cell carcinoma of the bladder has posed a constant dilemma to the practicing urologist. Previously, urine cytologies have been used and have been of value only in those instances in which they have been classified as diagnostic. Cytologies that reveal atypia or a high degree of suspicion have offered little help in the management of these patients. The current procedure of doing random mucosal biopsies using the cold cup biopsy forceps provides the pathologist with a sampling of the mucosa of the involved bladder so that a tissue diagnosis of sufficient magnitude, ranging from atypia to carcinoma in situ to frank carcinoma, may be established. This information may become valuable in determining alternate forms of management in these patients and may have a greater predictive value than customary urine cytology.

Diffuse pulmonary injury associated with gold treatment.

Two patients had diffuse, reversible pulmonary injury possibly owing to gold sodium thiomalate treatment: a 32-year-old woman with chronic inflammatory arthritis compatible with seronegative rheumatoid arthritis and a 32-year-old man with shoulder arthralgia. The patients had received 420 mg and 325 mg of gold sodium thiomalate, respectively. Cough and dyspnea began in the seventh and fifth weeks of therapy, respectively. In both patients x-ray study showed bilateral pulmonary infiltrates, with no evidence of pleural disease. The woman had no other manifestations of hypersensitivity to gold. The man had exfoliative dermatitis fever and anemia. Lung biopsies from both patients revealed lymphocytes and plasma cells infiltrating the alveolar septa and interstitial fibrosis. The woman improved slowly during four months after discontinuation of therapy. Pulmonary symptoms recurred after additional gold therapy, and again resolved when gold was discontinued. The man, treated with prednisone, showed prompt remission and remains will without medication.

Renal pelvic tumors.

A study was made of 35 patients with tumors of the renal pelvis. Tumors were indipendently graded and staged by a newly proposed method. The method of staging correlated well with grading of renal pelvic tumors and bore a direct relationship with prognosis. The high incidence of associated urothelial tumors, especially on the involved side, mandated radical nephroureterectomy including a bladder cuff as the treatment of choice.