Histopathologic prognostic factors in early stage cervical carcinoma.

The pathologist makes extensive assessments in cases of early stage carcinoma of the cervix. The following parameters are known to affect prognosis: capillary-lymphatic space invasion, depth of invasion, size of gross tumor, histologic type, grade (in adenocarcinoma), involvement by tumor of pelvic or para-aortic lymph nodes, and lymphoid response and immune status. These findings, along with clinical stage, best predict tumor behavior. Other observations are under investigation to evaluate their usefulness.

Paraneoplastic erythrocytosis in a young adult with an erythropoietin-producing Wilms' tumor.

Paraneoplastic erythrocytosis in patients with Wilms' tumors is exceedingly rare, with only three reported cases in the literature. We report a case of a young man with Wilms' tumor with a significant erythrocytosis but a normal serum erythropoietin level and a tumor that elaborated erythropoietin.

Artifact associated with the use of strong iodine solution (Lugol's) in cone biopsies.

The preoperative application of strong iodine solution (USP), commonly referred to as Lugol's solution, induces a histologic artifact in epithelial cells of cone biopsy material, most pronounced in dysplastic cells. Cellular shrinkage, cytoplasmic eosinophilia and vacuolization, development of visible intercellular space, and nuclear pyknosis with loss of chromatin detail are the major findings. Since the use of strong iodine solution (USP) is a common practice for delineating the ectocervical extent of disease prior to cone biopsy, the pathologist should recognize the artifact since its presence can make histologic interpretation difficult. Because the artifact may lead to interpretation error, alternatives to strong iodine solution (USP) should be considered.

Ploidy analysis by flow cytometry and fluorescence in situ hybridization in hydropic placentas and gestational trophoblastic disease.

Placentas with hydropic change may be hydropic degeneration (HD) or gestational trophoblastic disease (GTD), partial (PM) or complete (CM) hydatidiform mole. The separation of HD from PM and PM from CM by histological findings may be problematic in some cases and can be clarified with ploidy analysis. Fluorescence in situ hybridization (FISH) using a probe to chromosome 7 (D7Z1) was applied to tissue cut from paraffin blocks from 10 histologically representative cases each of HD, PM, and CM on which ploidy had been previously confirmed by flow cytometry from paraffin embedded tissue. Villous stromal cells and nonproliferative trophoblast were examined for number of signals/cell and percentage of cells/placenta with three hybridization signals. The mean number of hybridization signals/cell was HD 1.14; PM 1.79; and CM 1.17, with statistical significance between HD and PM (P < .0001), and PM and CM (P < .0001). The mean percentage of cells/placenta with three hybridization signals was HD 1.10%, PM 23.1%, and CM 2.11%, with statistical significance between HD and PM (P < .0001), and PM and CM (P < .0001). In addition, there was no overlap in the mean percentage of cells with three hybridization signals between HD and PM, and PM and CM. Chromosome 2 probe (D2Z1) was applied to tissues that had three chromosome 7 signals to exclude trisomy, and in all cases three signals were present confirming triploidy in PM. FISH can identify diploid and triploid hydropic placentas in paraffin-embedded tissue to assist in differentiating HD from PM, and PM from CM.

Detection of chromosomal abnormalities in the dysmorphic fetus using fluorescence in situ hybridization: evaluation for monosomy X genotype.

The cytogenetic abnormalities of dysmorphic fetuses who died in utero cannot be analyzed reliably by karyotyping. To overcome this obstacle, the authors applied fluorescence in situ hybridization (FISH) to formalin-fixed, paraffin-embedded tissue of two female infants and 13 female fetuses whose phenotypic features suggested possible Turner's syndrome. Previous cytogenetic evaluation of the amnionic fluid showed five were 45,XO karyotype; two were 46,XX karotype; and eight were of unknown karyotype. Karyotyping had been attempted on four of the unknown cases without success. The copy number of X chromosomes were correctly identified by FISH in all previously karyotyped cases. Of the remaining eight cases with unknown karyotype, three appeared to be XX, and five cases were identified as monosomy XO, confirming the suspicion of Turner's syndrome genotype. FISH is useful for confirming suspected Turner's syndrome genotypes in infants and macerated fetuses in which a karyotype cannot be obtained otherwise.

Angiosarcoma of the breast following segmental mastectomy complicated by lymphedema.

A patient is discussed who had angiosarcoma of her lymphedematous right breast develop four years after segmental mastectomy for infiltrating ductal carcinoma. The lymphedema developed and persisted after an indolent and recurrent postoperative infection. The possibility that the second malignancy is a consequence of the chronic lymphedema, similar to the angiosarcomas of lymphedematous extremities after radical mastectomy, is cautiously entertained. This hypothesis is worthy of consideration as more breast conservation surgery is being done, with or without adjuvant radiation therapy, and accumulating evidence suggests that lymphedema of the breast is a common complication of surgery followed by radiation.

Endometriosis causing ureteral obstruction.

Although endometriosis accounts for 15 to 20% of all gynecologic laparotomies, ureteral obstruction secondary to this disease has received little attention. This may be partly the result of diagnostic difficulties secondary to the unusual symptoms and atypical age groups of the patients. Five cases of obstructive uropathy caused by endometriosis are reported. Each case was documented by urologic evaluation as well as excretory urograms, surgical exploration, and histologic confirmation. All patients had significant radiographic and laboratory renal compromise, including marked degrees of hydronephrosis. Follow-up included excretory urograms obtained in all cases, which showed cure of original symptoms with radiographic improvement in four of five patients, whereas one patient developed chronic renal failure and hypertension. The present report suggests that with thorough preoperative assessment of the urinary tract, including contrast radiography in select cases of pelvic pathology, curative gynecologic and urologic surgery can be performed.

Liver transplant after massive spontaneous hepatic rupture in pregnancy complicated by preeclampsia.

BACKGROUND: Spontaneous hepatic rupture associated with preeclampsia is a rare but life-threatening situation. Several different surgical treatments have been described, depending on the severity of the rupture. Liver transplantation has become the mainstay for patients with end-stage liver disease. Transplantation in the setting of liver trauma or massive parenchymal disruption is not well defined. To our knowledge, this treatment has not been reported for spontaneous hepatic rupture in pregnancy. CASE: Massive, spontaneous hepatic rupture occurred in a patient at 36 weeks' gestation as a result of severe preeclampsia. Conventional surgical therapies were unsuccessful in controlling the massive hemorrhage. As a life-saving measure, the patient underwent total hepatectomy with the creation of an end-to-side portcaval shunt, thereby rendering the patient anhepatic. The patient was listed as urgently needing a liver for transplantation through the United Network for Organ Sharing. A suitable donor liver was located approximately 8 hours after the emergency hepatectomy. The patient underwent orthotopic liver transplantation after being maintained in an anhepatic state for almost 13 hours. The patient was discharged on postoperative day 41, suffering only from some ischemic lower extremity neuropathy secondary to hypovolemic hypotension occurring during the hepatectomy procedure. CONCLUSION: In the reported case, spontaneous hepatic rupture resulted in a massive hemorrhage that could not be controlled by previously reported techniques and required total hepatectomy followed by liver transplantation.

Histologic chorioamnionitis, microbial infection, and prematurity.

The purpose of this study was to relate histologic chorioamnionitis to the isolation of microorganisms from the freshly separated chorioamnion in women who had early preterm delivery (before 35 weeks' gestation) following spontaneous labor. Histologic chorioamnionitis was identified in 51 of 95 study subjects. It was more common in the second trimester (72%) than from 27-34 weeks' gestation (33%) (P less than .001). Culture specimens were obtained for aerobic and anaerobic bacteria, yeasts, mycoplasmas, and Chlamydia. Microorganisms were recovered from 38 subjects; all culture reports were negative in 36. A statistically significant association was demonstrated between histologic chorioamnionitis and positive culture results. If any microorganism was recovered, 68% of the subjects had histologic chorioamnionitis, versus 39% if all cultures were negative. Of cases of histologic chorioamnionitis in the third trimester, 92% were associated with positive cultures, compared with 54% in the second trimester. Our results suggest that histologic chorioamnionitis is not synonymous with infection, especially in the second trimester.

Primary leiomyosarcoma of the thoracic aorta presenting as a contained rupture.

Primary neoplasms of the aorta are rare and usually present with signs and symptoms due to intraluminal obstruction. A case of a 48-year-old man who presented with a contained rupture of the thoracic aorta secondary to a leiomyosarcoma is reported.

Promotion of neovascularization around hollow fiber bioartificial organs using biologically active substances.

A limiting factor of the long-term function of bioartificial organs is oxygen delivery to the encapsulated tissue. This study determined whether incorporation of endothelial cell growth factor (ECGF) into the alginate core of a hollow fiber bioartificial organ will induce neovascularization around the hollow fiber. Polyethersulfone (PES) and polyvinylidine difluoride (PVDF) hollow fibers were examined. Endothelial cell growth factor was incorporated into sodium alginate, extruded into the lumen of hollow fibers, and cured in calcium chloride. Samples without ECGF were fabricated and used as controls. Hollow fibers were implanted into 16 rats. For each rat, two implants were placed subcutaneously and two intraperitoneally, one with and one without ECGF at each site. Implants were placed on opposite sides of each animal. Implants were removed 65 days later and examined using immunohistochemical methods and light microscopy to determine the extent of neovascularization. A total of 64 implants were used. Most intraperitoneal implants were found free floating but were encased within a 100-microm thick avascular fibrotic reaction. This finding was independent from the presence of ECGF. Hollow fibers without ECGF, implanted subcutaneously, also had an avascular fibrotic reaction surrounding each implant. Subcutaneous implants with incorporation of ECGF within the alginate core had marked neovascularization within the fibrotic overgrowth that surrounded these implants. This was most prevalent in hollow fibers, with the thin separation layer facing the fiber lumen irrespective of limiting pore size. Potent angiogenic factors, such as ECGF, incorporated into diffusion chamber bioartificial organs can promote neovascularization around the subcutaneously implanted hollow fiber and may improve oxygen delivery to the tissue encapsulated within devices based on this technology.

Nasopharyngeal teratoma. Report of a case with prenatal diagnosis and postnatal management.

BACKGROUND: Oral teratomas are rare entities. CASE: A patient was referred for elevations in the maternal serum alpha-fetoprotein. On ultrasound examination, a cyst was seen protruding from the fetal mouth. Postnatally, a teratoma was found to be filling the neonate's oral cavity. CONCLUSION: This case illustrates problems in determining the etiology of head and neck masses antenatally. It also shows that teratomas can appear to regress and yield positive amniotic fluid alpha-fetoprotein and acetyl-cholinesterase. The appropriate perinatal management of this potentially devastating disorder includes preparation for establishing an airway following delivery.

Histiocytosis X of the vulva with a confusing clinical and pathologic presentation. A case report.

Histiocytosis X (HX) is a rare disorder of Langerhans cells and most commonly occurs in children. We report a case of HX of the vulva in a 76-year-old woman that clinically simulated a yeast infection of the vulva but histologically resembled an amelanotic melanoma. We briefly report the clinical and pathologic features of this case, which responded to vincristine followed by vinblastine and was in complete remission after nine months.

Adenomyoepithelioma of the breast: fine-needle aspiration biopsy and histologic findings.

Adenomyoepithelioma is an uncommon tumor of the breast which clinically presents as a discrete nodule and histologically is composed of lumenal spaces lined by a mixture of epithelial and myoepithelial cells. It has a spectrum of histologic appearances which are gradually gaining wider recognition. There are, however, only a few descriptions of the fine-needle aspiration biopsy (FNAB) findings in adenomyoepithelioma. We report the FNAB and histologic features of a mammary adenomyoepithelioma which contained a prominent epithelial component including a focus of marked epithelial atypia. This expands the spectrum of FNAB findings which have been reported in adenomyoepithelioma.

Malignant rhabdoid tumor of the uterus: report of a case with findings in a cervical smear.

Rhabdoid tumors are an uncommon group of neoplasms which share a distinctive morphology. We report the cytologic and histologic findings of a uterine rhabdoid tumor. The presence of rhabdoid cells on a cervical Papanicolaou (Pap) smear raises an intriguing differential diagnosis. Cytologists should be aware of this entity and consider rhabdoid tumor in the differential diagnosis when single malignant cells are noted on cervical Pap smear.

Cytomorphologic characteristics of thermal injury related to endocervical brushing following loop electrosurgical excision procedure (LEEP).

Loop electrosurgical excision procedure (LEEP) is gaining popularity in the United States as an alternative to other ablative and cone methods of treatment for preneoplastic conditions of the uterine cervix. The major advantage is that it is an outpatient procedure using local anesthesia. Post-LEEP evaluation of the endocervical canal can be accomplished by either endocervical curettage or cytobrush. We reviewed the immediate post-LEEP cytobrushes from 33 patients. Artifact related to the procedure was seen in all cases and included: 1) elongated endocervical cells with cytoplasmic "tails" and streaming nuclei ("taffy pulled"); 2) loose cellular aggregates with coalesced cytoplasm and "hockey stick" nuclei; 3) sheets of cells with frothy cytoplasm and shrunken thumbprinted nuclei; 4) nuclear enlargement; and 5) smudgy nuclear chromatin. The background ranged from bloody coagulum to watery proteinaceous material. Original diagnoses were negative in 25 cases. Eleven (44%) were considered abnormal on review. Of these, four were interpreted as having squamous intraepithelial lesions (SIL), one was atypical squamous cells of undetermined significance (ASCUS), and six had atypical glandular cells of undetermined significance (AGUS). It was not always possible to grade the degree of dysplasia. There was review agreement with 14 negatives, one SIL, one ASCUS, and one unsatisfactory specimen. Three AGUS were upgraded to SIL, and one unsatisfactory specimen was considered atypical on review. In conclusion it is possible to separate artifact from actual pathology on post-LEEP cytobrush specimens. Recognition of the characteristic changes seen on cytologic specimens obtained immediately following diathermy loop treatment will allow accurate identification of true abnormalities.

Fine needle aspiration cytologic features of hepatic metastasis of granulosa cell tumor of the ovary. Differential diagnosis.

The cytologic findings from a fine needle aspiration biopsy of hepatic metastases of a granulosa cell tumor are described. While the cytologic features of the tumor were characteristic, the early recurrence in an unusual site makes this case noteworthy. The differential diagnosis of granulosa cell tumors from other metastatic and primary liver tumors is discussed.

The effect of bipolar electrosurgical coagulation waveform on a rat uterine model of fallopian tube sterilization.

Laparoscopic bipolar electrosurgical sterilization has been employed for nearly two decades. This bipolar procedure was intended to reduce the incidence of unintended complications, such as bowel burns. However, compared to the monopolar procedure, it produced a higher failure rate. This study examines the role of the low power-high voltage coagulation waveform on the effectiveness of electrosurgical desiccation on the rat uterine model of the fallopian tube. Desiccations were performed with both Kleppinger and Storz forceps using generator settings from 2 to 6. Desiccations performed to the visual endpoint (blanch, swell, and collapse) required from 23.8 to 30.0 joules, although procedures performed at a generator setting of 2 required long application times, an average 15.4 sec (Storz) and 28.2 (Kleppinger). All bipolar procedures led to a loss of tissue at the desiccation site at 12 weeks postsurgery. Therefore, the electrosurgical coagulation waveform proved to be effective in producing adequate in vivo tissue destruction even at very low generator settings.

Human immunodeficiency virus testing in patients with invasive cervical carcinoma: a prospective trial of the gynecologic oncology group.

To determine the frequency of positive human immunodeficiency virus (HIV) serostatus among North American women 50 years of age or younger with invasive cervical cancer and to define their tolerance to treatment. Consenting patients with newly diagnosed invasive cervical cancer, age 50 or younger were tested by enzyme-linked immunosorbent assay. The study design anticipated that approximately 3% of patients would be HIV positive. After the accrual of 913 eligible and evaluable patients, interim analysis revealed that only 9/913 ( approximately 1%) patients were HIV seropositive, indicating that it would not be feasible to achieve the study objective. The study was closed to further accrual. Between 1994 and 1997, the frequency of positive HIV serostatus among North American women with newly diagnosed cervical cancer was quite low. As a consequence, no evaluation of response to treatment or treatment tolerance can be made.