[Is effective a shortened surveillance system of bloodstream infection?]. / Es eficaz un sistema de vigilancia acortado en las infecciones del torrente sanguíneo?

INTRODUCTION: Surveillance is necessary for bloodstream infection control. Daily monitoring of the central venous catheter (CVC) use, a time-demanding process, is the standard denominator to calculate the infection rate; surveillance of only one day per week has been proposed as alternative. OBJECTIVE: To determine whether surveillance of one day per week is similar to daily monitoring in a second-level hospital. MATERIAL AND METHODS: Daily monitoring of CVC utilization ratio was done during nine weeks in four locations of a second-level hospital. For each day, proportional differences respect to the global CVC utilization ratio was estimated. An ANOVA test was done to find differences between each weekday. RESULTS: CVC usage surveillance was performed for 9 weeks, so nine determinations were obtained for each weekday. No significant differences were found between each day (F = 2.20, p = 0.056). The lowest sampling discrepancy was found on Wednesdays. CONCLUSIONS: According to previous studies, and our own data, monitoring the CVC use one day per week is a reasonable alternative to the daily surveillance.

Primary schwannoma in a cervical lymph node.

BACKGROUND: Spindle cell neoplasms within lymph nodes are rare and include benign and malignant tumors and primary and metastatic tumors such as palisaded myofibroblastoma, leiomyoma, leiomyosarcoma, reticular cell neoplasms, and vascular sarcomas. Ancillary studies may help distinguish these neoplasms. METHODS: A 77-year-old white woman was seen with a painless, slowly growing mass of the left neck. Her clinical history was noncontributory. An excisional biopsy was performed without complication. There has been no recurrence, to date, of the lesion. RESULTS: Gross examination, microscopic examination, immunohistochemistry, and ultrastructural studies were consistent with the diagnosis of schwannoma arising within a lymph node. CONCLUSIONS: We report the first case of intranodal schwannoma arising in a cervical lymph node. The recognition of intranodal schwannoma is important because it is cured with excision, whereas some of the other diagnostic considerations for a spindle cell lesion within a lymph node may require radiation or chemotherapy.

Thyrolipoma and thyrolipomatosis: 5 case reports and historical review of the literature.

Because thyrolipoma (adenolipoma of thyroid) and thyrolipomatosis (diffuse lipomatosis of thyroid) are distinctively rare conditions with only few cases reported in the literature, we are reporting 5 additional cases. All the 5 patients were adult females, with ages from 38 to 79 years, who presented with thyroid masses. Four of the patients had normal thyroid function tests and one had mild hypothyroidism. All patients received partial or total thyroidectomy. The thyroid specimens showed either circumscribed yellow-tan masses (cases 1, 2, and 3) or diffuse yellow-brown discoloration (cases 4 and 5). Histologic examination revealed abundant mature fat infiltrating the affected thyroid tissue in 3 distinct patterns: (1) fat infiltration limited to follicular adenomas (thyrolipoma); (2) fat diffusely infiltrating throughout the thyroid gland (thyrolipomatosis); or (3) fat infiltration involving both follicular adenoma and their surrounding thyroid tissue. Because of the rarity of thyroid fat-containing lesions, confusion in differential diagnosis may occasionally occur. It is important to be aware during frozen section that these lesions may present as extrathyroidal nodules, which can be radioactive on intraoperative scan for parathyroid glands. In addition, a papillary thyroid carcinoma was also identified in one case of thyrolipomatosis. All patients recovered well after surgery and there has been no recurrence of the lesions after 1 to 24 years of clinical follow-up. In summary, we are reporting 5 rare cases of thyrolipoma and thyrolipomatosis with distinct histologic patterns. Previously reported cases of thyrolipomatosis were reviewed and analyzed with the current cases.

Warthin adenocarcinoma: analysis of 2 cases of a distinct salivary neoplasm.

Carcinomas arising in or from the epithelial component of preexisting parotid Warthin tumors (WTs) are rare; the other histologic types of carcinoma found to arise from WTs are adenocarcinoma not otherwise specified, undifferentiated, mucoepidermoid, squamous cell, and oncocytic. The aim of this study is to describe the clinicopathologic features of a distinct salivary gland neoplasm, previously undescribed, with a striated duct phenotype arising from WT. We have designated this neoplasm "Warthin adenocarcinoma" (WA). In this retrospective study, we searched the surgical pathology files of the Department of Pathology at The University of Texas M.D. Anderson Cancer Center for cases of malignant WT and salivary adenocarcinoma not otherwise specified diagnosed from January 1, 1985, through December 31, 2006, and evaluated patients' medical records and pathologic material. We obtained tissue sections and immunohistochemically stained them with antibodies against p63; Bcl-2; cytokeratin (CK)903, CK7, CK14, and CK18; antimitochondrial antibody (AMA); smooth muscle actin; calponin; S-100; and Ki-67. We identified 2 cases of WA; both patients were women, 44 and 60 years of age, with 4.0- and 4.5-cm tumors in the left parotid gland. Histologically, the tumors were composed of bilayered duct-like structures: The inner layer was formed by a single row of columnar oxyphilic cells expressing CK7, CK14, CK18, and AMA. The outer layer was composed of multiple layers of small round dark cells with scanty cytoplasm that expressed p63, Bcl-2, and CK903 and were focally positive for AMA and negative for myoepithelial markers. The Ki-67 proliferative indices were 20%; and 25%. A residual WT with transition to carcinoma was identified in both cases. Treatment had consisted of total parotidectomy with postoperative irradiation. Patients were free of disease 1 and 3 years after treatment. Warthin adenocarcinoma is a unique salivary gland carcinoma representing the malignant epithelial counterpart of WT. The identification of additional cases would help to better elucidate the line of differentiation of the tumor and further define its natural history.

Primary sinonasal choriocarcinoma.

Primary choriocarcinoma of sinonasal tract has not been previously documented. The aim of the study was to report, for the first time, 2 cases of primary sinonasal choriocarcinoma. The differential diagnosis is discussed and also the theories concerning the histogenesis of this neoplasm are briefly reviewed. Two male patients of 44 and 49 years of age complained of epistaxis and nasal obstruction of 2-week duration. Computerized axial tomographic scan of the head revealed an opacity of the left nasal cavity in one patient and a destructive lesion of the maxillary sinus in the other. Histopathologically, the lesions disclosed a dual cell population composed of cytotrophoblastic cells with uniform, round nuclei, clear cytoplasm, admixed with large multinucleated syncytiotrophoblastic cells, with bizarre nuclei, and abundant eosinophilic cytoplasm. Immunohistochemically, the tumors were notable for strong keratin and beta-chorionic gonadotrophin (HCG) positivity. The serum levels of HCG were 13 000 and 779 mIU/mL, respectively. One patient treated with maxillectomy, postoperative radiotherapy, and 5 courses of VIP chemotherapy (cisplatinum, etoposide, ifosfomide) died with brain metastases 10 months after diagnosis. The other patient received 4 courses of etoposide, and he is alive without tumor, 10 months after diagnosis. The serum levels of HCG are still negative. The present cases demonstrated the widespread distribution of germ cell tumors in the human body and lead to further support of the existence of primary choriocarcinomas in the sinonasal tract. Correct identification of this neoplasm is therefore important for institution of specific therapy.

Clinical features and differential diagnoses of solitary extramedullary plasmacytoma of the thyroid: a case report.

A 40-year-old woman presented with a rapidly enlarging palpable thyroid mass. The patient underwent a total thyroidectomy. The tumor fulfilled the criteria of primary solitary extramedullary plasmacytoma (SEP), including cellular expression of the CD138 and lambda light chain antibodies. Solitary extramedullary plasmacytoma of the thyroid occurs most commonly in patients with Hashimoto thyroiditis and must be distinguished from involvement of thyroid in multiple myeloma, inflammatory pseudotumor plasma cell variant, mucosa-associated lymphoid tissue lymphoma, and medullary carcinoma. The distinction is determined on the basis of histologic findings, immunohistochemical analysis, and other laboratory tests. Currently, no standard treatment exists for this entity. In this report, we discuss the differential diagnosis of SEP of the thyroid and the clinical features observed in this case.

Sinonasal chondromyxoid fibroma.

Chondromyxoid fibroma (CMF) is a rare benign cartilaginous tumor that usually arises from the metaphysis of long bones. In rare cases, however, CMF presents in unusual locations, such as the facial bones and sinonasal tract. We present a case of a 60-year-old woman with a CMF of the nasal septum. The initial radiographic findings were suggestive of a vascular tumor or a malignancy, but microscopic examination revealed the typical pathologic features of CMF, and SOX9 immunostaining confirmed its cartilaginous origin. The tumor was successfully excised, and the patient was free of disease at 12-month follow-up. Recognizing CMF is important when it presents in unexpected locations, especially because of its histologic resemblance to chondrosarcoma. We believe that the use of SOX9 in our case assisted in the recognition of the chondroid nature of the lesion and facilitated the diagnosis of CMF.

Liposarcoma of the head and neck: The University of Texas M. D. Anderson Cancer Center experience.

BACKGROUND: Our aim was to review our experience with liposarcoma of the head and neck region. METHODS: This is a retrospective case series at a comprehensive cancer center (1945-2005). RESULTS: Of 30 patients, 10 (33%) were initially misdiagnosed. Local recurrences were common (overall rate = 53%), and 4 patients (13%) developed distant metastases. Decreased crude disease-specific survival rates were significantly associated with recurrence (especially distant recurrence [0%]), age less than 38 years (40%), and pleomorphic subtype (45%); however, in Kaplan-Meier analyses, only larger tumor size, negative margins, round cell subtype, and pleomorphic subtype were associated with significantly decreased disease-specific survival (log-rank test p = .048, .041, .021, and .012, respectively). CONCLUSIONS: Based on this limited experience and existing literature, we continue to recommend surgery with negative margins as the treatment of choice and that adjuvant therapies should be considered in patients with high-grade histology, large tumors, positive margins, or certain subsites.

Eosinophil-rich squamous carcinoma of the oral cavity: a study of 13 cases and delineation of a possible new microscopic entity.

We report 13 cases of squamous cell carcinoma (SCC) of the oral cavity characterized by a prominent eosinophilic infiltration of the stroma. All patients were adults, 10 men and 3 women (aged 54 to 92 years; median, 71 years). They presented with tumors of the gingiva (5 cases), tongue (3 cases), palatine tonsil (2 cases), palate (2 cases), and mucosal aspect of lip (1 case). Metastatic involvement of regional lymph nodes was seen in 5 cases. The metastatic foci were associated with heavy eosinophilia as well. No patient had an abnormal eosinophil count in blood. Microscopically, the clusters of eosinophils were characteristically noticed in intimate admixture with the advancing edge of squamous carcinoma, either as nests or small tumor cords. The pattern of eosinophilic infiltration was comparable, regardless of tumor site or grade. Data from our series indicate that SCC with a reactive inflammatory infiltrate rich in eosinophils is consistently associated with stromal invasion. This observation may be useful in dealing with small tissue fragments where subepithelial stromal invasion cannot be easily assessed by conventional criteria. In addition, our data seem to confirm that eosinophil-rich SCC, although associated with metastatic involvement of cervical lymph node, seems to pursue a less aggressive course if compared with ordinary SCC.

Adenoid cystic carcinoma of the external auditory canal.

OBJECTIVE/HYPOTHESIS: To describe the clinical history and outcome of patients with adenoid cystic carcinoma (ACC) of the external auditory canal (EAC). STUDY DESIGN: Retrospective case series. METHODS: A search of our institution's tumor registry identified 22 patients with ACC of the EAC. Both clinical histories and pathology slides, when available, were reviewed. RESULTS: The mean age at diagnosis was 42 years (median, 38.5 years), and the most common presenting complaints were otalgia and ear canal mass. Nine patients (41%) developed recurrences at a mean of 8 years (median, 8 years) after initial diagnosis, six died of ACC, and three were living with distant metastases at their last follow-up. The mean duration of symptoms at the time of diagnosis was 7.7 years (range, 2-30 years) for patients who developed a recurrence after treatment vs. 1.2 year (range, 0-2 years) for patients who remained disease-free (P = .137). Every patient who had recurrent disease reported a duration of symptoms of >or=2 years (P = .013), and every patient with a duration of symptoms >2 years recurred (P = .002). There was a trend for more local recurrences after limited resection (P = .061). CONCLUSIONS: ACC of the EAC often recurs many years after definitive treatment. Although our sample size was too small to make definitive conclusions, we recommend aggressive local therapy with lateral temporal bone resection and adjuvant postoperative radiotherapy. In addition to successful local therapy, early diagnosis may be the only other effective means of preventing distant metastases.

Eosinophilic angiocentric fibrosis of the sinonasal tract.

Eosinophilic angiocentric fibrosis (EAF) is an uncommon inflammatory fibrosing lesion of the upper respiratory tract and orbit that occurs mainly in young to middle-aged women. The etiology of EAF is unknown. To our knowledge, approximately 28 cases have been previously reported in the English literature. We report here 3 additional cases of EAF of the sinonasal tract; 2 in women aged 19 and 31 years, and 1 in a man aged 49 years. The 19-year-old woman is the youngest patient with EAF ever described. The patients presented with a nasal cavity mass, face pain, or nasal obstructive symptoms of long duration.

Sinonasal teratocarcinosarcoma of the head and neck: a report of 10 patients treated at a single institution and comparison with reported series.

OBJECTIVES: To present the clinicopathologic features of 10 sinonasal teratocarcinosarcomas managed at a single center. Teratocarcinosarcoma is a rare morphologically heterogeneous and highly malignant neoplasm. Previous reports of these tumors have focused on their differential diagnosis and histogenesis and consisted of individual case reports and consultation based series. DESIGN: Review of patient medical records and microscopic slides of all tumor tissues. The histopathologic features for each tumor and the demographic, clinical, treatment, and follow-up information were recorded for each patient. Also, a comparison with previously reported series was performed. SETTING: The University of Texas M. D. Anderson Cancer Center. PATIENTS: Ten men ranging in age from 35 to 69 years (mean age, 53 years) were included in the study. They all experienced a short course of symptoms, with an average duration of 3.5 months, and 9 presented with nasal obstruction and epistaxis. Nine patients were treated with both surgery and irradiation. RESULTS: Histologically, the tumors showed primitive neuroepithelial elements and various malignant epithelial and mesenchymal components. Six patients had no evidence of disease by the end of follow-up, which ranged from 72 to 372 months. Three patients died of disease, and 1 patient was lost to follow-up. CONCLUSION: Sinonasal teratocarcinosarcoma of the head and neck is a histologically and biologically heterogeneous malignant neoplasm that is best managed with surgery and postoperative radiotherapy.

CRTC1/MAML2 fusion transcript in Warthin's tumor and mucoepidermoid carcinoma: evidence for a common genetic association.

Translocations and gene fusions have an important early role in tumorigenesis. The t(11;19) translocation and its CRTC1/MAML2 fusion transcript have been identified in several examples of both Warthin's tumor and mucoepidermoid carcinoma and are believed to be associated with the development of a subset of these tumors. To determine whether Warthin's tumor and mucoepidermoid carcinoma are genetically related, we used reverse transcriptase-polymerase chain reaction and DNA sequencing to analyze microdissected components of three tumors consisting of Warthin's tumor and mucoepidermoid carcinoma. We also investigated a metastatic melanoma to Warthin's tumor and a Warthin's carcinoma of the parotid gland for comparison. The fusion transcript was identified in both Warthin's tumor and matching mucoepidermoid carcinoma components of all three tumors, in the Warthin's carcinoma, and in the Warthin's tumor component but not in the metastatic melanoma. The results provide evidence for a link between the t(11;19) fusion gene and the development of a subset of Warthin's tumors with concurrent mucoepidermoid carcinoma and possible malignant transformation to Warthin's carcinoma. This article contains Supplementary Material available at http://www.interscience.wiley.com/jpages/1045-2257/suppmat.

Oral calcifying fibrous pseudotumor: case analysis and review.

Calcifying fibrous pseudotumor (CFT) is a rare distinct soft-tissue lesion characterized histologically by lymphoplasmacytic aggregates in a rich collagenized background with abundant psammomatous and dystrophic calcifications. Occurring most often in children and young adults, CFTs are clinically benign lesions that can form over a broad anatomic distribution, including in subcutaneous and deep soft tissues, as well as in serosal and visceral locations. The cause and mechanisms of pathogenesis of CFT are unknown. Simple excision with a margin of normal tissue is the treatment of choice. The risk for local recurrence is low. In this article, we describe a case of CFT in a 29-year-old woman with a 7-cm mass on the right upper gingiva and hard palate, discuss the differential diagnosis with other oral spindle cell lesions, such as, desmoid fibromatosis, nodular fasciitis, inflammatory myofibroblastic tumors, solitary fibrous tumor and also review the recent literature on this rare benign entity.

Epithelioid hemangioendothelioma of the head and neck: role of podoplanin in the differential diagnosis.

Epithelioid hemangioendothelioma is an uncommon vascular tumor of soft tissue and bone that may rarely occur in the liver, lung and the head and neck. We present five new cases of epithelioid hemangioendothelioma of the head and neck region diagnosed and managed in one institution in order to define the phenotypic characteristics, podoplanin immunohistochemical staining and the biological outcome. Podoplanin is a transmembrane mucoprotein selectively expressed in lymphatic endothelium and recently in some vascular neoplasms. The patients were comprised of two male and three female patients ranging in age from 4 to 71 years. The lesions were found in the gingiva, submandibular region soft tissue, nasal cavity and tongue, and ranged in size from 0.7 to 2.5 cm. All tumors manifested infiltrative cords and nests of epithelioid cells with occasional spindle morphology in a myxoid stroma. Immunohistochemical analysis of vascular and epithelial markers showed strong and uniform cytoplasmic reactivity for podoplanin and variable intensity and staining of CD31 and lack of cytokeratin staining in tumor cells. Surgical treatment included simple and wide local excisions. Of the three patients with follow-up, one developed lymph node metastasis and one had no evidence of disease 10 months after surgery. The patient with multiple recurrences and LN metastases was additionally treated with chemotherapy and is under consideration for radiation therapy. Hemangioendothelioma of the head and neck is: (1) a low-grade malignancy with a tendency for local recurrence and regional lymph node metastasis, (2) complete excision with negative margins is the treatment of choice for localized disease and (3) podoplanin may be useful in differentiating epithelioid hemangioendothelioma from non-vascular tumors.

Sclerosing mucoepidermoid carcinoma of the salivary glands.

Mucoepidermoid carcinoma (MEC) comprises approximately 30% of all salivary gland malignancies, making it the most common malignant tumor of the salivary glands. Multiple histologic variants with a wide range of differentiation have been described. Sclerosing MEC (SMEC) is a rare subtype that may be misdiagnosed as a benign reactive condition or low-grade non-SMEC malignancy. We report 4 cases of SMEC and evaluated them with Her-2/neu and MIB-1 to determine whether an association exists between the histologic grade and immunohistochemical findings. In 3 cases, histologic examination demonstrated relatively well-circumscribed, nonencapsulated tumors composed of extensive central sclerosis with keloid-like stroma and scattered epithelial islands of low-grade MEC. In the fourth case, the tumor showed similar sclerotic stroma; but the epithelial component was of intermediate grade. In all 4 cases, eosinophils and neutrophils were part of the inflammatory infiltrate; and the edges were surrounded by lymphoid tissue, with germinal center formation and residual epithelial islands. A Mayer mucicarmine stain revealed abundant intracytoplasmic mucin. We found MIB-1 labeling indices of 5% or less in cases 1, 2, and 3 and 12% in case 4, suggesting an association between MIB-1 index and tumor grade. The tumors were negative for Her-2/neu in all 4 cases. The latter seems to bear no relationship to tumor grade.

Heterotopic parathyroid inclusion in a cervical lymph node.

BACKGROUND: During the pathologic examination of neck dissection specimens, unexpected findings within the lymph nodes may be discovered. Such findings may include benign epithelial inclusions, a second primary tumor, or chronic inflammatory diseases. METHODS: We report a case of a 59-year-old man who underwent a laryngectomy and bilateral neck dissection for a right transglottic squamous carcinoma of the larynx. During the procedure, a large lymph node measuring 2.5 x 2.2 x 0.8 cm was found at the right level IV. RESULTS: Histologic examination of the neck dissection specimen revealed benign parathyroid inclusions in the enlarged lymph node. The heterotopic cells expressed parathyroid hormone. This case represents a unique example of heterotopic parathyroid inclusions in a cervical lymph node. CONCLUSION: Parathyroid tissue should be included in the differential diagnosis of cervical intranodal epithelial inclusions.

Survival in patients with synovial sarcoma of the head and neck: association with tumor location, size, and extension.

BACKGROUND: The medical literature on synovial sarcoma (SS) of the head and neck region is limited. Thus, we determined whether clinical characteristics and treatment were associated with recurrence and survival rates in patients with SS of the head and neck. METHODS: We retrospectively identified patients with a pathologic diagnosis of SS of the head and neck at our institution (a large tertiary comprehensive cancer center) and compared recurrence and survival rates by clinical characteristics and treatment. RESULTS: Forty patients with SS of the head and neck were identified from 1945 to 2004 (first case in 1968), representing <5% of all head and neck sarcomas seen at our institution during this time period. Twenty-three patients (58%) had the monophasic histologic subtype, 15 (38%) biphasic, and 2 unspecified. Most patients were male (73%), with a median age of 29 years. SS tumors were most commonly located in the neck (60%); thus, the most common symptoms were a neck mass and neck pain. No patients reported a history of radiation exposure. Higher disease-specific and overall survival rates were associated with upper aerodigestive tract location, tumors of < or =5 cm, and tumors did not extend into bone. Patients treated with surgery and adjuvant radiotherapy had higher survival and lower recurrence rates than did those treated with surgery alone or a combination of surgery, radiotherapy, and chemotherapy. This difference was not significant, and the subgroups were small, with substantial confounding by adverse prognostic factors. CONCLUSIONS: SS of the head and neck is extremely rare, and our results should be viewed with caution given the relatively small group size and treatment over a 36-year period. Survival rates were associated with tumor location, size, and extension. Treatment of SS of the head and neck should be directed toward complete surgical resection. Given the known sensitivity of SS to contemporary chemotherapy, a multimodality approach should be considered in the perioperative setting, especially in high risk patients.

Pharyngeal teratocarcinosarcoma: review of the literature and report of two cases.

Teratocarcinosarcomas are rare malignant neoplasms histologically characterized by the presence of benign and malignant epithelial and mesenchymal elements. They are seen almost exclusively in the sinonasal tract of men. We report two cases of teratocarcinosarcomas involving the posterior pharyngeal wall in a 55-year-old male and 60-year-old men. The tumors consisted of epithelial components including squamous, neuroendocrine, and glandular structures; neuroepithelium, and mesenchymal components with prominent rhabdomyoblastic, osteoblastic and chondroid differentiation. Immunohistochemical studies demonstrated markers characteristic of each component. The tumors were resected, and the patients received postoperative radiation therapy. One patient is alive with recurrent tumor 33 months after treatment and the other died 26 months after radiation therapy with distant metastasis.

Salivary mucoepidermoid carcinoma: revisited.

Mucoepidermoid carcinoma (MEC) is a malignant epithelial neoplasm composed of varying proportions of mucous, epidermoid, intermediate, columnar, and clear cells and often demonstrates prominent cystic growth. MEC is usually subclassified as low, intermediate, or high grade on the basis of its histologic features, including the presence of cystic spaces, cellular differentiation, proportion of mucous cells, growth pattern, type of invasion, and cytologic atypia. Because even low-grade neoplasms may metastasize, the term mucoepidermoid tumor is inappropriate. The 3-level grading approach to tumor classification has found general acceptance among pathologists; differences in biologic behavior can be demonstrated even though clinical stage has become a better prognosticator. However, in the case of MEC, no universal agreement exists regarding which histologic grading criteria are most the useful, and grading has varied. These issues have led to the investigation of more subjective systems. We describe these new schemes, the histologic variants of MEC, and the ancillary methods that allow for further stratification of patients with MEC, especially for patients with grade 2 tumors, which have a variable and unpredictable clinical course.