Multifocal extraparotid Warthin's tumours mimicking metastatic squamous cell carcinoma of the upper neck.

BACKGROUND: Warthin's tumours can show features of pseudo-neoplasia. They do not usually cause problems for diagnosis and management when present within the parotid gland. However, extraparotid Warthin's tumours that are associated with pseudo-neoplasia upon cytological analysis can mimic metastatic malignant disease. The case of a patient presenting with multifocal extraparotid Warthin's tumours is described. CASE REPORT: A 57-year-old male smoker presented with rapidly growing upper neck lumps. Fine needle aspiration cytology, magnetic resonance imaging and positron emission tomography findings were compatible with metastatic squamous cell carcinoma secondary to either an unknown primary upper aerodigestive or a parotid malignancy. The patient subsequently underwent total conservative parotidectomy and modified radical neck dissection. Final histology findings revealed multifocal benign Warthin's tumours with four extraparotid components. CONCLUSION: Warthin's tumours may present outside the parotid gland, present with multifocal lesions and mimic metastatic disease. Frozen section examination prior to radical resection should be considered to guide management.

A clinical review of 128 cases of head and neck tuberculosis presenting over a 10-year period in Bradford, UK.

AIMS: To analyse the epidemiology, presentation and diagnosis of head and neck tuberculosis (TB). METHODS: We conducted a 10-year retrospective study of all cases of tuberculosis of the head and neck region occurring in Bradford, UK. RESULTS: Of a total of 1315 cases of TB, 128 presented with head and neck TB (12 per cent of which (15/128) were in children). Cervical lymph nodes were most commonly involved (87 per cent, 111/128), other sites being: salivary glands (five cases); larynx, oral cavity, eyes and ears (two cases each); and skin, thyroid, nasopharynx and retropharyngeal space (one case each). Patients' ethnic origins were Asian (89 per cent, 114/128), Caucasian (10 per cent, 13/128) and African (one case). Only 26 per cent (33/128) had constitutional symptoms, and 20 per cent (25/128) had a coexistent site of TB. Only 39 per cent (40/105) of surgical specimens were sent for culture. CONCLUSIONS: Isolated head and neck TB is not uncommon. Atypical presentations render diagnosis challenging, so awareness aids early diagnosis. Mycobacterial cultures should be performed, where possible, for diagnosis.

Heterotopic gastric mucosa in the cervical oesophagus (inlet patch) and globus pharyngeus--an under-recognised association.

Globus pharyngeus is a symptom commonly encountered in ENT practice. The usual complaint is that of the sensation of a ball or lump in the throat generally unaccompanied by dysphagia. This sensation is often more pronounced when taking an 'empty swallow'. The precise mechanism of this remains enigmatic in many cases. Irritant factors such as gastroesophageal reflux, postnasal drip and excessive throat clearing may be contributory factors as may be stress and psychological influences. Although gastric type mucosa occupying the cervical oesophagus has been long recognised, mainly in the specialised gastrointestinal literature, there appears to be more limited awareness of the condition in ENT practice and the clinical significance of such heterotopia is not well established. We present five recent cases of globus pharyngeus encountered in our ENT practice in which rigid pharyngoesophagoscopy and biopsy revealed heterotopic gastric mucosa within the postcricoid and cervical oesophagus constituting a so-called gastric 'inlet patch'. One case re-presented with invasive adenocarcinoma within a short time. Herein we compare and contrast inlet patch with columnar lined oesophagus, discuss the potential clinical significance of inlet patch and comment upon further management of the condition.

Management of lymphoma patients in a cancer unit: an audit of 15 years' experience in a district general hospital.

The objectives were to analyse data obtained in a district general hospital medical oncology unit over a 15-year period, and to provide a comparator for standards of care for lymphoma patients in new cancer units. Prospectively collected data were analysed on 208 consecutive patients presenting with lymphoma, on an 'all-comers' basis, between 1981 and 1996. Treatment was with radiotherapy and/or chemotherapy, according to local protocols. The outcome measure was survival from the date of diagnosis. The 5-year actuarial survival was 72.7% for Hodgkin's disease and 55.7% for non-Hodgkin's lymphoma. Age and stage of disease were the only predictors of survival in a multivariate analysis. Histological classification was not a useful predictor of survival in this analysis. Survival figures comparable with those obtained nationally and across Europe are attainable in a cancer unit. Multiple pathways of referral of lymphoma patients operate in our region.

Unilateral and segmental localised polycystic kidney disease.

Unilateral and segmental localised polycystic disease is a rare type of cystic disease of the kidney. It takes the form of a segmental cystic abnormality in one kidney morphologically identical to the autosomal dominant adult form of polycystic kidney disease. The clinical, radiological, and pathological appearances of a case are described. The differential diagnosis and a possible pathogenic mechanism are discussed.

Renal failure in a patient with chronic lymphocytic leukaemia treated with fludarabine.

The case history of a man with refractory chronic lymphocytic leukaemia who developed acute renal failure following treatment with fludarabine is presented. A renal biopsy specimen showed features of mesangiocapillary glomerulonephritis, a rare occurrence in chronic lymphocytic leukaemia. The rapid cytocidal action of fludarabine may result in the development of renal glomerular lesions when used to treat a well differentiated B cell malignancy.

Elastofibroma of the forefoot.

Elastofibroma is an uncommon soft tissue lesion that most often presents as a mass in the lower scapular region of elderly female subjects. The authors report an elastofibroma arising in the right forefoot of a 63-year-old woman. Pain over the plantar aspect of the head of the third metatarsal preceded the formation of a tender mass. Although rare, elastofibroma should be considered in the differential diagnosis of painful conditions and tumors of the forefoot.

Arterial endothelialitis in chronic renal allograft rejection: a histopathological and immunocytochemical study.

Transplantation is the preferred method of renal replacement therapy in end-stage renal failure. Short- and medium-term graft survival is good but, in the longer term, grafts are lost due to vascular obliteration, i.e. chronic vascular rejection. The pathogenesis of these changes is unclear. We carried out a histopathological and immunocytochemical study of 31 vessels from 20 graft nephrectomies. Four patterns of arterial pathology were identified: (1) subendothelial inflammation ('endothelialitis') with little intimal thickening; (2) 'Endothelialitis' with thickening; (3) Intimal thickening without 'endothelialitis'; and (4) Intimal thickening with calcification and cholesterol clefts ('natural atherosclerosis'). We suggest that the lesions of chronic vascular rejection evolve, at varying rates, from an early 'endothelialitis' to a later stage with pronounced intimal thickening but no subendothelial inflammation. These changes probably reflect a delayed type hypersensitivity response involving activated macrophages and T lymphocytes and smooth muscle cell proliferation.

Rapidly fatal necrotising fasciitis caused by Streptococcus pyogenes.

AIMS: To describe the morbid anatomical and bacteriological features in a series of five cases of rapidly fatal Streptococcus pyogenes necrotising fasciitis. METHODS: Post mortem and bacteriological examinations were made of five patients dying within 48 hours from rapidly fatal necrotising fasciitis. RESULTS: All five cases died rapidly from a toxic Streptococcus toxin syndrome as a result of developing necrotising fasciitis following trivial injury. CONCLUSIONS: Necrotising fasciitis caused by Streptococcus pyogenes infection can be rapidly fatal. This is probably the result of a toxic shock syndrome. Rapid, early diagnosis and swift and probably empirical treatment is required to avoid a fatal outcome.

Multiple lymphomatous polyposis and the role of fine needle aspiration cytology.

Multiple lymphomatous polyposis is an uncommon but distinctive form of gastrointestinal lymphoma. Clinical symptoms may closely resemble those of colorectal carcinoma and diagnostic confusion may result. The condition has a characteristic pathological appearance and immunophenotype which is important in allowing distinction from other less aggressive forms of gastrointestinal lymphoma. We report a case of this unusual condition in which the diagnosis was aided by fine needle aspiration cytology.

Intranasal malignant melanoma arising in an inverted papilloma.

A case of intranasal malignant melanoma arising in the epithelium of an inverted papilloma is described. The use of immunohistochemistry to delineate the in situ component of the malignant tumour is illustrated and the characteristic features of malignant melanomas at this site discussed.

Renal transplant aspiration cytology. Role for simple morphological criteria.

Fine-needle aspiration (FNA) is a well-recognized technique for sampling solid organs. It is used in renal transplantation to clarify the cause of a poorly functioning graft. Differential scoring techniques with respect to peripheral blood cell populations, and immunocytochemistry have been employed in this context. We describe the use of simple morphological criteria alone in renal transplant FNA. We compare these with needle biopsy and clinical parameters and show their value in the detection of active cellular rejection. Their limitations are discussed within the framework of other patterns of transplant pathology.

Gastric antral vascular ectasia: a problem of recognition and diagnosis.

Gastric antral vascular ectasia ('water melon stomach') is a poorly documented cause of occult upper gastrointestinal blood loss. We describe a case which emphasises the clinical and pathological difficulties that can be encountered in making this elusive diagnosis.

Heterogeneity of glutathione S-transferase isoenzyme expression in renal disease.

Recent work has suggested that glutathione S-transferase (GST) enzymuria may be used to assess renal injury in transplant kidneys. There is little work investigating the possibility of using glutathione S-transferase enzymuria to assess other renal diseases and this study was undertaken to evaluate the localisation of GST isoenzymes in various glomerular and tubular pathologies so that the specificity of these enzymes as markers of tubular injury could be defined. Immunostaining was carried out to establish the location of alpha and pi class GST in renal biopsies from patients with a wide variety of renal diseases including membranous glomerulonephritis, minimal-lesion glomerulonephritis, mesangial proliferative glomerulonephritis, loin pain haematuria syndrome, and renal allograft rejection. In the cases of glomerulonephritis studied, alpha class GST was detected in proximal tubules and pi class GST in distal convoluted tubules, podocytes, and Bowman's capsule. The majority of cases of glomerulonephritis showed a heterogeneous pattern of expression of both isoenzymes: that is, there was variation in intensity of staining both in single tubules and also between tubules as opposed to the uniform staining pattern observed in normal kidneys. The location of enzymes in the cases of glomerulonephritis was the same as that in normal kidneys and we were unable to demonstrate any de novo expression of GST isoenzymes. However, seven out of ten renal allograft biopsies showed expression of pi class GST in proximal tubules which were atrophic. Provided there is no significant tubular atrophy, urinary release of these enzymes may be used to localise renal tubular injury.(ABSTRACT TRUNCATED AT 250 WORDS)