Lethal autonomous weapon systems and respect for human dignity.

Much of the literature concerning the ethics of lethal autonomous weapons systems (LAWS) has focused on the idea of human dignity. The lion's share of that literature has been devoted to arguing that the use of LAWS is inconsistent with human dignity, so their use should be prohibited. Call this position "Prohibitionism." Prohibitionists face several major obstacles. First, the concept of human dignity is itself a source of contention and difficult to operationalize. Second, Prohibitionists have struggled to form a consensus about a property P such that (i) all and only instances of LAWS have P and (ii) P is always inconsistent with human dignity. Third, an absolute ban on the use of LAWS seems implausible when they can be used on a limited basis for a good cause. Nevertheless, my main purpose here is to outline an alternative to Prohibitionism and recognize some of its advantages. This alternative, which I will call "Restrictionism," recognizes the basic intuition at the heart of Prohibitionism - namely, that the use of LAWS raises a concern about human dignity. Moreover, it understands this concern to be rooted in the idea that LAWS can make determinations without human involvement about whom to target for lethal action. However, Restrictionism differs from Prohibitionism in several ways. First, it stipulates a basic standard for respecting human dignity. This basic standard is met by an action in a just war if and only if the action conforms with the following requirements: (i) the action is militarily necessary, (ii) the action involves a distinction between combatants and non-combatants, (iii) noncombatants are not targeted for harm, and (iv) any and all incidental harm to non-combatants is minimized. In short, the use of LAWS meets the standard of basic respect for human dignity if and only if it acts in a way that is functionally isomorphic with how a responsible combatant would act. This approach leaves open the question of whether and under what conditions LAWS can meet the standard of basic respect for human dignity.

Can CT-Based Stone Impaction Markers Augment the Predictive Ability of Spontaneous Stone Passage?

Introduction: A number of clinical and radiological predictors of either stone impaction or ureteral stone passage (SP) have been proposed. We aimed at identifying the key predictors of successful SP by using readily available CT-based tools/measurements. Methods: Patients presenting to the emergency department from February 2017 to February 2018 with an acute unilateral ureteral stone confirmed on non-contrast CT and managed conservatively were followed for SP. Patients with renal impairment, sepsis or requiring emergent intervention were excluded. Patients were followed at 1 month to confirm SP (stone collection/repeat imaging) or failure of passage. The CT variables analyzed included: Stone factors [location, size, volume, HU density (HUD)], impaction factors [ureteral HUD above and below the stone, maximal ureteral wall thickness (UWT) at the stone site, contralateral UWT, and ureteral diameter above and below the stone]. Binary logistic regression analysis was performed to identify predictors of SP. Results: Forty-nine patients met study inclusion criteria, of whom 32 (65.3%) passed the stone without further intervention. Patients with successful passage were more likely to have smaller, lower volume and less dense stones located in the distal ureter (p < 0.01). Lower ureteral HUD below the stone, lower maximal UWT, and lower ureteral diameter above the stone were associated with successful passage (p < 0.01). On multivariable logistic regression analysis, only maximal UWT at the stone site was a significant independent predictor of SP outcome (p = 0.01). Youden's criterion identified 2.3 mm as the optimal UWT cut-off point, which will accurately predict SP with 82.4% sensitivity and 87.5% specificity. Conclusions: Maximal UWT at the stone site was the most significant predictor of successful passage in acute unilateral ureteral stones, with an optimal cut-off point of 2.3 mm. Further prospective studies are needed to accurately predict spontaneous SP.

Utility of stone volume estimated by software algorithm in predicting success of medical expulsive therapy.

INTRODUCTION: We sought to assess the accuracy of using stone volume (SV) estimated with a software algorithm as a predictor for stone passage in a trial of medical expulsive therapy (MET). METHODS: We identified patients with ureteral stones discharged from the emergency department on MET. Patients with infection, non-ureteral stones, or needing immediate surgical intervention were excluded. For each stone, longest dimension (LD) was recorded, and SV was estimated by a computed tomography (CT)-based region-growing (RG) algorithm and standard ellipsoid formula (EF). Stone passage within 30 days was assessed via electronic chart and followup phone call. RESULTS: Fifty-one patients were included for analysis (53±16.7 years, 24% female). The mean LD was 4.85±2.02 mm. The mean SV was similar by EF and RG (0.051±0.057cm3 vs. 0.049±0.052 cm3, p=0.28). Thirty-three (65%) patients passed their stone, while 18 (35%) did not. The mean LD for passed stones vs. failed passage was 4.1±1.7 mm vs. 6.2±1.8 mm (p=0.0002); the mean EF volume was 0.028±0.035 cm3 vs. 0.093±0.066 cm3 (p=0.00007); and the mean volume by RG was 0.028±0.027 cm3 vs. 0.088±0.063 cm3 (p=0.00005). CONCLUSIONS: The clinical utility of SV estimated by software algorithm as a predictor for success of MET has not previously been examined. We demonstrated that spontaneously passed stones had a significantly smaller volume than those requiring intervention. Further prospective studies are needed to validate these findings and establish volume thresholds for probability of stone passage.

How Accurate Are We in Estimating True Stone Volume? A Comparison of Water Displacement, Ellipsoid Formula, and a CT-Based Software Tool.

INTRODUCTION: To compare the accuracy and reliability of stone volume estimated by ellipsoid formula (EFv) and CT-based algorithm (CTv) to true volume (TV) by water displacement in an in vitro model. MATERIALS AND METHODS: Ninety stone phantoms were created using clay (0.5-40 cm3, 814 HU ±91) and scanned with CT. For each stone, TV was measured by water displacement, CTv was calculated by the region-growing algorithm in the CT-based software AGFA IMPAX Volume Viewer, and EFv was calculated by the standard formula π × L × W × H × 0.167. All measurements were repeated thrice, and concordance correlation coefficient (CCC) was calculated for the whole group, as well as subgroups based on volume (<1.5 cm3, 1.5-6 cm3, and >6 cm3). RESULTS: Mean TV, CTv, and EFv were 6.42 cm3 ± 6.57 (range: 0.5-39.37 cm3), 6.24 cm3 ± 6.15 (0.48-36.1 cm3), and 8.98 cm3 ± 9.96 (0.49-47.05 cm3), respectively. When comparing TV to CTv, CCC was 0.99 (95% confidence interval [CI]: 0.99-0.995), indicating excellent agreement, although TV was slightly underestimated at larger volumes. When comparing TV to EFv, CCC was 0.82 (95% CI: 0.78-0.86), indicating poor agreement. EFv tended to overestimate the TV, especially as stone volume increased beyond 1.5 cm3, and there was a significant spread between trials. CONCLUSIONS: An automated CT-based algorithm more accurately and reliably estimates stone volume than does the ellipsoid formula. While further research is necessary to validate stone volume as a surrogate for stone burden, CT-based algorithmic volume measurement of urinary stones is a promising technology.

Amyloidoma of Stomach: A Case Report.

OBJECTIVE: Amyloidomas are tumor-like deposits of amyloid. Amyloidoma of the gastrointestinal tract is rare. To the best of our knowledge, this is the first instance of diagnosis of an amyloidoma in the gastrointestinal tract by fine needle aspiration (FNA). STUDY DESIGN: We report a case of a 64-year-old male with a history of ulcerative colitis and primary sclerosing cholangitis who was incidentally found to have a mass in the stomach wall. RESULTS: Initially thought to be gastrointestinal stromal tumor, FNA demonstrated the lesion to be amyloidoma with a prominent giant cell reaction. This was further confirmed by mass spectrometry. This is the only case report of diagnosis of a gastric amyloidoma by FNA. CONCLUSION: The presence of a florid giant cell reaction in the absence of ulceration or an inflammatory or neoplastic lesion should alert the pathologist to the possibility of an amyloidoma. This is the only case report of diagnosis of a gastric amyloidoma by FNA.

Perivascular Leiomyomatosis: A Unique Case Report.

There are 3 histologically benign smooth muscle neoplasms that have unusual growth patterns. These include intravascular leiomyomatosis, benign metastasizing leiomyoma, and leiomyomatosis peritonealis desseminata. We report a unique case of perivascular leiomyomatosis. The tumor showed multiple nodules of benign smooth muscle with some of the nodules closely associated with the periphery of the medial muscle layer of venous channels. All the neoplastic nodules were located on the outer surface of venous channels, thus precluding a diagnosis of intravascular leiomyomatosis. To the best of our knowledge, this is the first documentation of such an entity.

Epiphyseal Primary Diffuse Large B-Cell Lymphoma of Bone.

Primary lymphoma of bone (PLB) confined to the epiphysis has only been described in four other patients. Due to the rarity of this entity, diagnosis has often been delayed, leading to mismanagement with adverse clinical consequences. We report a fifth case of primary epiphyseal lymphoma of bone located in the left distal medial femoral epiphysis of a 13-year-old boy. Radiographic and histologic features of PLB are discussed, along with a review of the literature and pitfalls of misdiagnosis. The patient initially presented with six months of progressive left knee pain with an associated loss of passive range of motion. Imaging revealed a mixed radiolucent lesion within the left distal medial femoral epiphysis with cortical breakthrough. A core biopsy was performed revealing a blue round cell tumor. Thanks to modern immunohistochemistry techniques, a diagnosis of primary lymphoma of bone was quickly made. The patient thus avoided further surgical intervention and received the appropriate treatment of chemotherapy, with subsequent rapid resolution of the lesion. This case highlights the necessity of including primary lymphoma of bone in all epiphyseal lesion differential diagnoses, especially in the pediatric patient population when aggressive radiographic features are present.

Synovial Sarcoma Mimicking Pleomorphic Hyalinizing Angiectatic Tumor of Soft Parts: A Case Report.

Synovial sarcoma is a high-grade sarcoma commonly affecting young adults. The sites of involvement include soft tissue near joints, lung, pleura, mediastinum, larynx, kidney, and buttocks. Histologic types include monophasic, biphasic, and undifferentiated. We report a unique case of synovial sarcoma with low-grade histologic features mimicking pleomorphic hyalinizing angiectatic tumor (PHAT) with indolent behavior for a period of 10 years. The tumor showed angiectatic blood vessels with fibrinous cuffing, hypocellular and hypercellular spindle cell areas with rare mitoses, and focal atypia in a myxoid background. TLE1 was positive with SYT gene translocation detected on fluorescent in situ hybridization. Cases of myxoinflammatory fibroblastic sarcoma and myxofibrosarcoma have been reported as exhibiting histologic features of PHAT. However, to the best of our knowledge, cases of synovial sarcoma mimicking PHAT have not been reported.

Osteogenic melanoma: report of a case mimicking osteosarcoma and review of the literature.

A 32-year-old male presented with a right thumb lesion of 11-month duration. A clinical diagnosis of pyogenic granuloma was entertained but the lesion failed to respond to conservative therapy and eventually necessitated amputation of his thumb. MRI of the right thumb showed an ill-defined, heterogeneously enhancing, infiltrating mass within the dorsal soft tissues abutting the distal phalanx and measuring 4.2 × 2.4 × 0.7 cm. Histologically, the tumor was composed of a high-grade osteosarcoma with a chondrosarcomatous component localized within the underlying bone and a more superficial spindle cell component in the overlying soft tissue. The epidermis was focally ulcerated overlying the lesion. The key to the diagnosis was provided by intense staining of the spindle cell component for S100 protein indicative of a spindle cell melanoma. The presence of an associated osteogenic sarcomatous component established a final diagnosis of osteogenic melanoma. The localization of this element to phalangeal bone is distinctly unusual and resulted in the close resemblance to a primary osteogenic sarcoma.

Extraskeletal osteosarcoma arising in myositis ossificans: a case report and review of the literature.

We report a case of a 23-year-old female with pain and fullness in the right popliteal fossa. An MRI scan demonstrated an ossified enhancing soft tissue mass. Evaluation of the resected specimen showed a high-grade extraskeletal osteosarcoma juxtaposed to the three zones of myositis ossificans. At 1-year follow-up the patient is alive and disease free. A review of the literature purporting to document such an association failed to demonstrate a single case in which an osteosarcoma and MO with its zonal architecture co-existed.

Subcutaneous extraskeletal osteosarcoma of the forearm: a case report and review of the literature.

Extraskeletal osteosarcoma (ESOS) originating in the subcutaneous tissue is a rare occurrence, accounting for less than 10 % of ESOS cases. Osteosarcoma of extraskeletal origin accounts for approximately 2-4 % of all osteosarcomas, and 1 % of soft tissue sarcomas. We report a case of an 80-year-old female with an isolated primary subcutaneous tumor of the forearm. After imaging, surgical excision, and pathological analysis, the diagnosis of a subcutaneous osteosarcoma was made. This report documents the clinical and pathological findings of subcutaneous ESOS in this case, along with a review of previous cases of subcutaneous ESOS.

A rare case of pseudotumor formation associated with methyl methacrylate hypersensitivity in a patient following cemented total knee arthroplasty.

Hypersensitivity to orthopedic implant materials has been well documented with potential catastrophic consequences if not addressed pre-operatively. The spectrum of reactions is wide, from mild non-specific pain with localized erythema to severe periprosthetic inflammatory destruction and pseudotumor formation. It is therefore essential to identify patients who have or are at risk for implant-associated hypersensitivity. Although metal sensitivity is commonly cited as the cause of these reactions, methyl methacrylate (MMA) has rarely been implicated. To the best of our knowledge, methyl methacrylate-associated pseudotumor formation has not yet been described. The following is a case report of a 68-year-old female who, after undergoing a routine cemented right total knee arthroplasty, developed a painless, enlarging mass during a 13-year period. This mass was found to be a pseudotumor in association with methyl methacrylate hypersensitivity. A review of pseudotumor pathogenesis, methyl methacrylate hypersensitivity, and preoperative preventative care is discussed.

Predicting histological subtypes of follicular variant of papillary thyroid carcinoma based on cytomorphology. Can cytomorphology optimize use of molecular testing?

INTRODUCTION: Follicular variant papillary thyroid carcinoma (FVPTC) can be further subclassified into one of 3 subtypes: non-invasive encapsulated FVPTC, invasive encapsulated FVPTC, and infiltrative FVPTC. Longitudinal and molecular studies have demonstrated that, in terms of both molecular profiles and prognosis, encapsulated FVPTC is comparable to follicular adenoma, invasive FVPTC to follicular carcinoma, and infiltrative FVPTC to classic PTC. To improve triaging and prevent overtreatment of patients with FVPTC, we sought to determine cytologic features likely to occur within each subtype. METHODS: A laboratory database search from 2010-2015 was conducted to identify patients with biopsy-proven FVPTC and prior fine-needle aspiration. Surgical specimens were reviewed to determine the appropriate subcategorization. Accompanying cytology reports were reviewed for features common in classic PTC and follicular neoplasms. RESULTS: Encapsulated variants were more likely to be graded as Bethesda category 4 compared with invasive or infiltrative variants. In contrast, infiltrative variants were more likely to be graded as Bethesda categories 5 and 6 compared with invasive or encapsulated variants. Compared with the encapsulated variant, infiltrative FVPTC was more likely to have nuclear pseudo-inclusions (31.82% versus 8.11%, P = 0.0468) and less likely to have microfollicular architecture (22.73% versus 54.05%, P = 0.0374). CONCLUSION: This study identified cytomorphologic differences between encapsulated and infiltrative FVPTC. With a higher threshold of suspicion for FVPTC, improved awareness of the differences between these subtypes and incorporation of molecular testing, it is likely that the Bethesda category can be revised and patient triaging can be significantly improved.

Giant Cell Tumor of the Larynx Treated by Surgery and Adjuvant Denosumab: Case Report and Review of the Literature.

Giant cell tumor of the larynx (GCTL) is a rare entity; only 34 cases have been reported in the literature. We report a case of GCTL in a 46 year-old male presenting clinical, radiographic, histological and therapeutic features. Previously reported cases are also reviewed.

Malakoplakia of the thyroid gland: a case report and review of literature.

Malakoplakia is a rare granulomatous disease that most commonly occurs in the urinary tract. It is characterized by sheets of histiocytes with granular basophilic inclusions and Michaelis-Gutmann bodies. We present an exceedingly rare case of malakoplakia of the thyroid in a 54-year-old Caucasian woman on immunosuppressive therapy for renal transplant performed in 1994.

Beta-human chorionic gonadotropin producing osteosarcoma of the sacrum in a 26-year-old woman: a case report and review of the literature.

Ectopic secretion of beta-human chorionic gonadotropin is considered a poor prognostic marker in epithelial tumors. However, very few cases have been reported in sarcomas. We present the case of a 26-year-old female who presented with a metastatic osteosarcoma. She underwent usual testing prior to starting treatment and was found to have elevated levels of beta-human chorionic gonadotropin. As the patient was not pregnant, another source of beta-human chorionic gonadotropin secretion had to be considered. The tumor cells demonstrated positive staining for beta-human chorionic gonadotropin by immunohistochemistry, and serum levels of beta-human chorionic gonadotropin were used to monitor tumor progression and response to chemotherapy. We review the literature and discuss a potential role of beta-human chorionic gonadotropin in the treatment of such patients.

Perirenal myelolipoma diagnosed on imprint: case report and review of the literature.

Myelolipomas are benign tumors containing adipose tissue and hematopoeitic elements which occur most commonly in the adrenal glands. Extra-adrenal myelolipomas are uncommon with few cases of renal and perirenal myelolipomas in the literature. These cases may be difficult to diagnose based on radiology alone and intraoperative diagnosis can be extremely important in determining the course of surgery. Due to the lipomatous component of the tumor it may be technically difficult to prepare adequate frozen sections; this problem can be obviated by utilization of cytologic imprint preparations. We present a case of perirenal myelolipoma diagnosed intraoperatively utilizing cytologic imprint preparations stained with toluidine blue and hematoxylin and eosin.

Retrospective blinded review of interpretational diagnostic discrepancies in surgical pathology: 18 years of experience at a tertiary care facility.

We evaluated our quality assurance (QA) methods and QA consensus conference model for assessing the rate of interpretational diagnostic errors and trend of errors. Using monthly QA reports from review of frozen section- permanent section correlation and amended reports, all cases with interpretational diagnostic errors were identified. Retrospective blinded review of study cases were independently performed by all staff pathologist and subsequently discussed in QA conference sessions. 277 (.07%) interpretational errors were identified from 1993-2010. Errors with patient consequences comprised 15% of all errors, 4% of which were major errors. More than half (57%) of the errors were identified on review of frozen section- permanent section correlation and accounted for 64 % of all errors with patient consequence and 45% of major errors. Comparison of errors between two equally divided time periods (1993-2001 and 2002-2010) showed significant error reduction (p< 0.05). 64% of all errors, 61% of errors with patient consequence and 73% of major errors were a consequence of incorrect interpretation of the biologic behavior of the neoplasm. To conclude, we propose this quality assurance model as an effective tool for assessing interpretational errors, particularly those with significant patient consequences, enhancing participation of pathologists and reducing errors.

Ossifying fibromyxoid tumor of the breast mimicking fibroadenoma: a case report and differential diagnoses.

An 80-year-old woman presented with a palpable mass in the right breast. Mammographic findings were consistent with calcified fibroadenoma. An ultrasound was performed that showed a solid nodule with peripheral calcification. A core biopsy was obtained that revealed a spindle cell proliferation with a shell of mature bone. The histologic features, in combination with immunohistochemical studies, were those of an ossifying fibromyxoid tumor. Complete excision of the specimen further confirmed the diagnosis. To the best of our knowledge, this is the first reported case of ossifying fibromyxoid tumor occurring in the breast. We review the current literature on ossifying fibromyxoid tumor and discuss the differential diagnoses when confronted with bland spindle cells on a core biopsy of the breast.