Establishment and identification of small cell lung cancer cell lines having classic and variant features.

Using a chemically defined medium containing hydrocortisone, insulin, transferrin, 17 beta-estradiol and selenium, with or without serum supplementation (2.5% v/v), continuous cell lines can be established from 72% of all fresh biopsy specimens of small cell lung cancer (SCLC) containing tumor cells. No differences were observed in the rate of establishing cell lines from newly diagnosed untreated patients, or from patients who have relapsed from prior therapy, or from a variety of different organ sites. Biochemical characterization of 50 SCLC cell lines for the expression of L-dopa decarboxylase; bombesin-like immunoreactivity; neuron-specific enolase, and the brain isozyme of creatine kinase, revealed that SCLC cell lines can be subdivided into two distinct classes: classic SCLC cell lines (35 lines), which express elevated levels of all four biomarkers; and variant SCLC cell lines (15 lines) which have undetectable levels of L-dopa-decarboxylase and bombesin-like immunoreactivity, but continue to express neuron-specific enolase and the brain isozyme of creatine kinase. The presence of the latter two markers distinguishes variant lines fron non-SCLC cell lines. In addition, four distinct classes were identified morphologically. The biomedical differences among established SCLC cell lines may account for the differences in response rates to cytotoxic therapy observed in newly diagnosed SCLC patients. A prospective study of biomarker characterization of SCLC tumors will determine if clinical differences exist between classic and variant SCLC tumors.

Ankylosing spondylitis and systemic lupus erythematosus: a rare HLA combination.

The condition of a 43-year-old man fulfilled the strict diagnostic criteria for both ankylosing spondylitis and systemic lupus erythematosus. To our knowledge, this is the fist verified report of the concurrence of these rheumatic diseases. An unusual combination of genetically determined markers seems to have caused an increased risk for the development of both disorders.

Diagnosis of progressive multifocal leukoencephalopathy by brain biopsy with biotin labeled DNA:DNA in situ hybridization.

DNA:DNA in situ hybridization using a cloned JC virus (JCV) DNA probe labeled with biotin confirmed the presence of JCV DNA in formalin-fixed, paraffin-embedded brain biopsies from four cases of progressive multifocal leukoencephalopathy (PML). Only small pieces of tissue were available in each case. Detection of the JC DNA:DNA hybrids was carried out by affinity cytochemistry. JCV DNA was identified predominantly in the nuclei of interfascicular oligodendrocytes in demyelinated areas of the biopsies. JC virus was isolated from one case, and the diagnosis of PML was substantiated in all cases by electron microscopic identification or immunocytochemical labeling of JC viral antigen. In situ hybridization using a biotin labeled JCV DNA probe is a specific, sensitive and convenient method for confirming the diagnosis of PML in suspected cases evaluated by brain biopsy.

Sea-blue histiocytes in a patient with lymphoma.

A middle-aged man with lymphocytic lymphoma had numerous sea-blue histiocytes in his bone marrow, splenomegaly and thrombocytopenia. Thus, his illness mimicked that of patients with the primary syndrome of the sea-blue histiocyte. However, the paucity of sea-blue histiocytes in his spleen, the absence of neurologic disease, his age and the ultrastructure of his abnormal histiocytes were all evidence for the presence of the acquired syndrome. The pathogenesis of sea-blue histiocytosis and the relationship between acquired cases and the primary syndrome are discussed.

Renal sarcoidosis with superimposed postinfectious glomerulonephritis presenting as acute renal failure.

We describe two patients with sarcoidosis with lesions of granulomatous interstitial nephritis (GIN) and postinfectious glomerulonephritis (GN). Both patients presented with heavy proteinuria, hematuria, and renal failure. Renal histology in both showed GIN and glomerular changes of proliferative GN with hump-like subepithelial deposits by electron microscopy of postinfectious GN. Antecedent history of pneumonia was present in one, and ASO titer was elevated in the other. The proteinuria and azotemia improved in both with steroid therapy. Reports of "postinfectious" or diffuse proliferative GN in patients with sarcoidosis are rare. The authors are unaware of reports of concomitant sarcoid GIN and postinfectious GN. Although acute renal insufficiency or failure can occur with GIN or other more common renal lesions primary glomerular disease should be considered in patients with sarcoidosis who present with renal dysfunction. This is a US government work. There are no restrictions on its use.

Eosinophilic products lead to myocardial damage.

Eosinophils have been associated with endomyocardial fibrosis. However, their effect on the myocardium and the reactions they elicit have not been emphasized. We describe four patients with extensive myocardial eosinophilic infiltration with and without endomyocardial fibrosis. Patients with a short duration of disease had eosinophilic infiltrates, myocardial eosinophilic abscesses containing granular eosinophilic material, and/or Charcot-Leyden crystals with and without profuse histiocytic and giant cell reaction with granuloma formation. In the early phase, the granular eosinophilic material can be visualized by the Luna stain and/or by electron microscopic examination. In patients with a long duration of symptoms, well-developed granulomas and profuse fibrosis are seen and eosinophilic material may not be visualized. Toxic eosinophil granular protein may be involved in the development of these lesions.

Pulmonary hyalinizing granuloma. Electron microscopic and immunologic studies.

We present a case of pulmonary hyalinizing granuloma (PHG). On light microscopy, the pulmonary nodular lesions consisted of extracellular, eosinophilic hyaline lamellae. Histochemical stains of the hyaline lamellae for amyloid were focally positive and the diagnosis of amyloidosis was seriously considered; however, on electron microscopic examination, the hyaline lamellae consisted of electrondense, compact, amorphous material quite unlike fibrillar amyloid. Although circulating immune complexes containing IgA were detected in our patient, immunoperoxidase stains did not reveal immunoglobulins in the hyaline lamellae. This case illustrates the value of electron microscopy in differentiating PHG from amyloidosis and supports the hypothesis that PHG represents an exaggerated immune response.

Malacoplakia of epididymis.

Malacoplakia localized to the epididymis is described. Ultrastructural study revealed the presence of bacterial bodies in phagolysosomes of malacoplakic macrophages. The possible role of the phagocytosed bacteria in the pathogenesis of malacoplakia is briefly discussed.

Adult polyglucosan body disease.

We describe a case of adult polyglucosan body disease with characteristic clinical symptoms of peripheral neuropathy, upper motor neuron signs, and bowel and bladder dysfunction. Sural nerve biopsy revealed diagnostic intra-axonal polyglucosan bodies. On electron microscopic examination, the inclusions were located mainly within myelinated nerve fibers and consisted of branched filaments that were 6 to 8 nm wide. The diagnosis of adult polyglucosan body disease was confirmed by a skin biopsy from the axilla showing similar inclusions in myoepithelial cells of apocrine glands. This report provides additional evidence that skin biopsy, to date advocated by a single case report only, may be a less invasive and simpler diagnostic alternative to sural nerve or brain biopsies.

Ependymoma: ultrastructural studies of two cases.

Several unusual ultrastructural findings in two ependymomas are reported. In case 1, a grade I ependymoma of the fourth ventricle, there were rosettes, perivascular pseudorosettes, and tumor cells having unusual intracytoplasmic vacuoles by light microscopy. Ultrastructurally, these vacuoles were frequently microrosettes as well as scattered, degenerated cytoplasmic processes of tumor cells. The lumina of some of the microrosettes were bordered by abnormally long and malformed zonulae adherentiae. In case 2, a recurrent grade III ependymoma of the third ventricle, there were rosettes and perivascular pseudorosettes as well as more cellular and anaplastic areas by light microscopy. Ultrastructurally, the cytoplasmic processes of tumor cells in perivascular pseudorosettes contained frequent dense-core vesicles and occasional parallel arrays of microtubules. These structures do not occur in normal mammalian ependymal cells but do occur in the ependymal tanycyte, a related cell that is plentiful in the walls of the third ventricle. Thus some of the tumor cells of this third ventricle ependymoma appear to have differentiated as tanycytes.

Oral hairy leukoplakia: an ultrastructural study and review of the literature.

A 39-year-old, homosexual, Caucasian man with a 9-month history of acquired immunodeficiency syndrome by reduced CD4 lymphocyte count alone was found to have extensive, asymptomatic, nonremovable, corrugated, white patches on the lateral borders and ventral aspects of the tongue typical of oral hairy leukoplakia (OHL). Histologically, irregular hyperparakeratosis, acanthosis, and clusters of ballooned keratinocytes in the stratum spinosum were present in the biopsied lateral tongue. Some of the superficial ballooned keratinocytes had peripherally beaded nuclei, whereas others had ground glass intranuclear inclusions. Ultrastructurally, the ballooned keratinocytes had three important findings of diagnostic significance. First, frequent herpesvirus nucleocapsids were largely confined to superficial ballooned keratinocytes having marginated and condensed chromatin. In searching for herpesvirus nucleocapsids, the marginated and condensed chromatin was an invaluable marker for cells harboring the virions. Second, the marginated and condensed chromatin frequently had a distinctive punched-out or cribriform appearance. Third, the ground glass intranuclear inclusion bodies consisted of central, medium electron-dense, finely granular material containing frequent herpesvirus nucleocapsids and partially surrounded or capped by prominent, clumped chromatin. The patient died with progressive multifocal leukoencephalopathy 24 months after OHL was diagnosed.

Canalicular adenoma of the buccal mucosa. An ultrastructural and histochemical study.

A canalicular adenoma that occurred in the minor salivary glands of the buccal mucosa in a 62-year-old black man was examined by electron microscopy and histochemistry. The ulcerated bowl-shaped tumor consisted mostly of ductlike tubules of columnar and cuboidal epithelial tumor cells which resembled intercalated duct cells ultrastructurally. Tumor cells resembling myoepithelial cells were not associated with these tubules. Less frequently, there were narrow tubules and cords adjacent to the capsule. Occasional cells in these cords contained variable amounts of microfilaments, often associated with focal densities, and thus resembled myoepithelial cells in varying stages of differentiation. Other noteworthy ultrastructural findings in this neoplasm included marked replication of the basal lamina of capillaries and the presence of a single, luminally oriented cilium in a tumor cell lining a tubule.

Trichomoniasis complicating esophageal intramural pseudodiverticulosis: diagnosis by transmission electron microscopy.

A 58-year-old African-American man presented with a progressive esophageal stricture of unknown etiology complicated by esophageal candidiasis, broncho-esophageal fistula, four episodes of aspiration pneumonia, and a 40-lb weight loss. He ultimately required an esophagectomy. Pathologic examination showed marked thickening of the esophageal wall by submucosal pseudodiverticula typical of esophageal intramural pseudodiverticulosis (EIPD) and extensive mucosal and submucosal chronic inflammation and fibrosis. Small, oval cells with ill-defined nuclei were present in lumens of some pseudodiverticula, light microscopically. Their exact nature could not be determined by light microscopy. The diagnosis of trichomoniasis became apparent only after transmission electron microscopic study of these cells demonstrated characteristic features of trichomonad protozoa. These included four anteriorly placed flagella with kinetosomes, a recurrent flagellum associated with an undulating membrane, a costa, a peltar-axostylar complex, and a small Golgi body with parabasal filaments. This case of EIPD is unusual in that the associated broncho-esophageal fistula and trichomoniasis have not been previously reported as complications of EIPD.

Tumor of the broad ligament in von Hippel-Lindau disease of probable mullerian origin.

A rare neoplasm seen in women with von Hippel-Lindau disease is the papillary cystadenoma of the broad ligament, only three cases of which have been reported. All three exhibited characteristic histologic features identical to those of epididymal tumors that occur in affected patients, and were presumed to be of wolffian origin. This is the case of a broad ligament tumor in a woman with von Hippel-Lindau disease that had features more consistent with a mullerian rather than wolffian origin. This is the first report of a broad ligament tumor of probable mullerian origin in von Hippel-Lindau disease.

Malignant Schwannoma associated with von Recklinghausen's neurofibromatosis.

A series of 46 malignant schwannomas occurring in soft parts of patients having von Recklinghausen's neurofibromatosis was analyzed. The diagnosis of malignant schwannoma was based upon the occurrence of malignant spindled cells closely resembling Schwann cells in the neoplasm and the close association or origin of the malignant schwannoma in a neurofibroma (27 tumors), or a large peripheral nerve (31 tumors). Additional histologic features useful in making the diagnosis of malignant schwannoma included the arrangement of the spindled tumor cells in a whorled pattern about thin-walled, gaping blood vessels, perivascular cellular proliferation and the presence of prominent myxoid stroma containing abundant hyaluronidase-sensitive acid mucopolysaccharides. Nuclear palisading was present in only one case. Eight tumors containing both neoplastic Schwann cells and rhabdomyoblasts and five containing both neoplastic Schwann cells and rhabdomyoblasts (malignant "Triton" tumors) and five containing foci of malignant cartilage cells were included in the series. The neoplasms occurred principally in adults (median age, 34 years) and were most common in the lower extremity (18 cases) and retroperitoneum (11 cases). A mass with or without pain was the most common presenting symptom (28 cases). The median size of excised tumors was 11 cm. The malignant schwannomas were highly malignant neoplasms, causing the death of 39 patients within five years and two patients within 6--10 years after diagnosis. Only four patients were alive and free of tumor 5--15 years after diagnosis.

Cytomembranous inclusions in myelodysplastic syndrome.

A 56-year-old African-American man presented with fever of unknown origin and peripheral blood and bone marrow findings of myelodysplastic syndrome (MDS): refractory anemia with an excess of blasts in transformation that subsequently progressed to acute myeloblastic leukemia (AML). Ultrastructural study of two bone marrow specimens having the findings of MDS revealed frequent, large tubuloreticular structures (TRS) in lymphocytes, plasma cells, macrophages, and endothelial cells. Several cylindrical confronting cisternae (CCC) were present in macrophages and an endothelial cell. Two partially developed CCC were present in a plasma cell. TRS and CCC were not observed in eight subsequent bone marrow specimens obtained during the 9-month course of the AML. This is the first reported occurrence of TRS and CCC in MDS. These inclusions are probably related to an unidentified viral infection or possibly to cytokines released by the dysplastic hematopoietic cells.

Spontaneous return of normocalcemia. Association with long-term hypoparathyroidism.

A 58-year-old man was admitted to the hospital with the superior vena cava (SVC) syndrome. The patient had a 13-year history of hypocalcemia resulting from surgically induced hypoparathyroidism, which he controlled with calcium lactate. Nine months before admission, he discontinued his daily therapy and still remained in a normocalcemic state. After he had the SVC syndrome, a small-cell tumor of the lung was found. His serum calcium level decreased after radiation of the tumor mass, suggesting that the tumor may have been secreting a substance producing the normocalcemia. A substance was extracted from the tumor that reacted immunologically like parathyroid hormone.

Hemodialysis-associated amyloidosis presenting as lingual nodules.

Hemodialysis has permitted long-term survival of patients with kidney failure, but not without many complications, such as mineral loss from bones, secondary hyperparathyroidism, and increased risk of infection. Recently a new form of amyloidosis, AB2M, has been characterized that is specifically associated with long-term dialysis. The tissues and organs affected by deposits of AB2M appear to differ from those affected by the other major types of amyloidosis; AB2M affects mainly the carpal ligament, synovia of large joints, juxtaarticular bone, and intervetebral disks, while involvement of the oral tissues has been rare. We present here a case in which the biopsy of superficial lingual deposits of AB2M led to the recognition that the patient had developed hemodialysis-associated amyloidosis. It is suggested that periodic inspection of the oral soft tissues for signs or symptoms of amyloidosis should become a part of the dental care of patients undergoing dialysis.

Intestinal spirochetosis and acquired immunodeficiency syndrome: ultrastructural studies of two cases.

Two cases of intestinal spirochetosis (IS) with acquired immunodeficiency syndrome are reported. In case 1, a 48-year-old homosexual black man presented with a 1-month history of alternating watery diarrhea and constipation, which dissipated following the removal of two colonic hyperplastic polyps containing IS. In case 2, a 26-year-old homosexual black man presented with a 3-month history of persistent bloody diarrhea and was found to have chronic shigellosis and IS. Pathologic findings of IS were similar in both cases. Basophilic fringes typical of IS covered the surfacing colonic epithelium and consisted of dense growths of spirochetes adherent to and oriented perpendicular to the plasma membranes of the surfacing epithelium. The spirochetes measured 3 to 5 microns in length and 0.2 micron in width, contained four to eight axial fibrils, and closely resembled Brachyspira aalborgi ultrastructurally. These cases are notable because the histopathologic changes of IS were more extensive than generally described. There was involvement of both the right colon and rectum by IS in case 2, and in both cases there was extension of the IS down into the crypts of Lieberkühn, spirochetal invasion of the colonic mucosa, and a conspicuous inflammatory response by macrophages in the underlying lamina propria.