[Acute appendicitis in a boy with an earlier appendectomy and a second appendix]. / Voor de 2e maal acute appendicitis bij een jongen met eerdere appendectomie.

A 17-year-old boy who had already undergone appendectomy, presented with a one-day history of severe pain in his right lower abdomen. Physical examination and other investigations indicated acute appendicitis. On exploratory laparotomy, a second, inflamed appendix was found. Appendectomy was carried out, and the patient made a good recovery. Pathological examination of the organs removed at each operation confirmed that during both procedures an intact and clearly inflamed appendix had been removed. A double appendix is a rare clinical entity and may be associated with other congenital abnormalities. Doctors should be aware of the possibility of appendiceal duplication to avoid delay in diagnosis and treatment.

Tuberculous aortitis with an aortoduodenal fistula presenting as recurrent gastrointestinal bleeding.

Tuberculous aortitis with a tuberculous mycotic aneurysm and an aortoduodenal fistula was diagnosed in a 38-year-old man with tuberculous cervical lymphadentitis and a 3-month history of recurrent gastrointestinal bleeding, in whom extensive investigation of the digestive tract had not revealed a bleeding lesion. Either by septic embolism or by direct extension from a neighboring focus, tuberculous infection can cause a mycotic aortic aneurysm with subsequent fistulation to the duodenum.

Angioleiomyoma of the diaphragm.

We report a case of a large symptomatic angioleiomyoma of the diaphragm. The tumor was diagnosed by computed tomography and videothoracoscopic biopsy. We removed the tumor through a left thoracolaparotomy. Three months later, a local recurrence was removed through an upper midline laparotomy. The patient remains without evidence of a recurrence 48 months after the second operation.

The cytological screening history of 469 patients with squamous cell carcinoma of the cervix uteri; does interval carcinoma exist?

BACKGROUND: To determine whether interval carcinomas occurred and to determine the level of screening-participation by women who developed a cervical carcinoma. METHODS: A retrospective study of the cytological history of 469 patients diagnosed between January 1980 and December 1989 with cervical squamous cell carcinoma in 12 hospitals in the western part of The Netherlands. Clinical data, and cervical smear histories in 3.5 years preceding the diagnoses were obtained. Cervical smears diagnosed as Pap I, II or IIIA were traced for review. RESULTS: 306 patients' data were completed. Two hundred and twenty-three patients (72.9%) had never been screened and 83 patients (27.1%) had had at least one smear, of which 39 were normal. The percentage of women over 54 was higher in patients who had never been screened (58%) than in those screened (46%). Women over 54 were in higher Figo stage. Interval carcinoma was proven in six of 306 (2%) patients. Of the normal smears 53% were false negative. CONCLUSION: The high number of non-participants still forms the main reason for the failure of cervical cancer screening. Secondly, the assumed existence of frequent interval carcinoma could not be demonstrated. There are grounds for changing the age limits of the current Dutch screening program without changing the screening interval.

Fine needle aspiration of focal liver lesions.

Fourteen percutaneous fine needle aspirates (FNAs) of focal liver lesions performed under ultrasound guidance at the Sultan Qaboos University Hospital (SQUH), Oman, between January 1991 and October 1992, are presented. Ten of these were cytologically diagnosed as hepatocellular carcinomas (HCC). The patients' ages ranged from 50 to 70 years and eight of these were males. The important diagnostic cytological criteria of HCC were found to be increased nucleocytoplasmic (N/C) ratio, trabecular pattern, atypical naked nuclei, bile production by malignant hepatocytes and absence of bile duct epithelium. Carcinoembryonic antigen (CEA) positivity of bile canaliculi by cross-reaction with biliary glycoprotein I (BGP I) made possible the differentiation of HCC from metastases. We stress the importance of cell blocks as these often constitute microbiopsies. Ultrasound-guided FNA of focal liver lesions is recommended as a simple, easy and quick procedure.

Fulminant pulmonary aspergillus infection occluding the aortic arch after high-dose antileukemic chemotherapy.

After antileukemic chemotherapy a granulocytopenic patient experienced a rapidly progressive left-sided pneumonia with pleuritic pain. After 1 week, a sudden occlusion of all aortic branches was followed by death. At postmortem, a huge thrombus in the aortic arch caused by Aspergillus invasion from the left lung was found.

Failure to diagnose fatal disseminated toxoplasmosis in a bone marrow transplant recipient: the possible significance of declining antibody titres.

A 46-year-old patient with acute myelogenous leukaemia developed lethal disseminated toxoplasmosis 8 weeks after allogeneic bone marrow transplantation. Clinical features included pulmonary infiltrates, respiratory insufficiency and neurological signs. Post-transplantation toxoplasma serological tests were characterised by declining IgG titres and failure to detect IgM, whereas titres of IgG against the various herpes viruses remained constant and even increased over the same period. Circulating toxoplasma antigen could not be detected. Post mortem, specific immune complexes were identified in serum. Autopsy revealed widely disseminated toxoplasmosis with several foci in the brain, lungs and various other organs as well as concomitant infection with cytomegalovirus.

Tumor markers for ovarian cancer. A comparative immunohistochemical and immunocytochemical study of two commercial monoclonal antibodies (OV632 and OC125).

A comparative immunohistologic and immunocytologic study was performed to assess the immunoreactivity of the monoclonal antibodies OC125 and OV632, both directed at antigens present on epithelial ovarian tumors. OC125 reacted with 53 of 59 ovarian carcinomas, 20 of 20 uterine carcinomas, and 25 of 111 nongynecologic tumors (including 20 of 38 breast carcinomas). OV632 was demonstrated in 47 of 59 ovarian carcinomas, 11 of 20 uterine carcinomas, and only 7 of 111 nongynecologic tumors. With OV632 no reactivity was found in carcinomas of the breast or the gastrointestinal tract. Cytologic preparations of malignant effusions of patients with ovarian cancer showed reactivity with OC125 in 32 of 35 cases, and OV632 with positivity in 34 of 35 cases. Mesothelial cells in reactive effusions were OC125 positive in 16 of 20 cases but never showed positivity with OV632. The authors conclude that for histopathology a combination of OC125 and OV632 offers high sensitivity (0.86) and specificity (0.89) for ovarian cancer. For cytology, OV632 is the most specific tumor marker available.

Malignant melanoma in fine needle aspirates and effusions. An immunocytochemical study using monoclonal antibodies.

The value of monoclonal antibodies (MAbs) for the immunodetection of keratin, vimentin and two melanoma-associated antigens recognized by NKI/C3 and NKI/Bteb for the diagnosis of malignant melanoma has been previously established on histologic preparations. In the present study, cytologic preparations from 20 fine needle aspirates and effusions from patients with malignant melanoma were evaluated using these antibodies. Twenty of 20 smears were negative for keratin, and 20 of 20 smears were positive for vimentin. Positivity for NKI/C3 was seen in 12 of 12 cases studied, and for NKI/Bteb in 12 of 13 cases. These results indicate that a panel of MAbs consisting of anti-keratin, anti-vimentin, NKI/C3 and NKI/Bteb is useful for a more accurate diagnosis of malignant melanomas on cytologic preparations. The expression of these antigens in melanoma cells in cytologic smears can be a valuable aid in the detection of primary (noncutaneous) and metastatic melanomas by fine needle aspiration.

Immunohistochemical detection of the ras oncogene product p21 in advanced ovarian cancer. Lack of correlation with clinical outcome.

The monoclonal antibody RAP 5 immunoreactive with the ras gene product p21 was used in an immunohistochemical study of 57 patients with advanced ovarian cancer and in 28 normal ovaries. The pattern of the staining of various tumor specimens was similar to the germinal epithelium of normal ovaries, whereas the intensity of staining was more enhanced in carcinomas than in normal ovaries. However, we found a lack of correlation among staining intensity of RAP 5 and the histologic type, the histologic grade, the ploidy class, and the clinical outcome.

The value of tumour marker CA 125 in surgical pathology.

CA 125 is a tumour marker located primarily on non-mucinous epithelial ovarian tumours and which is recognized by the monoclonal antibody OC 125. In this study the value of CA 125 in surgical pathology was assessed. In fresh frozen material, the expression of CA 125 was demonstrated in 82% of 83 epithelial ovarian neoplasms using the indirect immunoperoxidase technique. In addition, all adenocarcinomas of cervix (n = 5) and endometrium (n = 15) tested expressed CA 125, and 25 of 111 (22%) non-gynaecological malignant tumours were positive. The positive cases included 20 breast carcinomas, one carcinoma of the stomach and one of the colon. Using a commercial kit on routinely fixed, paraffin embedded material, CA 125 positivity was demonstrated in 29 of 36 (80%) serous cystadenocarcinomas after pronase pre-treatment of the sections, in contrast to 100% (n = 25) positivity on frozen tissue sections. CA 125 can, therefore, be demonstrated in routinely fixed paraffin embedded material, although the number of positive results is less than in fresh frozen sections.

Hepatocellular carcinoma, adenoma, and focal nodular hyperplasia. Comparative histopathologic study with immunohistochemical parameters.

For the evaluation of differential diagnostic parameters, hepatocellular carcinoma (HCC, n = 26), liver cell adenoma (n = 4), focal nodular hyperplasia (n = 8), and secondary liver tumors (n = 15) were studied with histologic and immunohistochemical methods. The study was performed on formalin-fixed, paraffin-embedded tissue sections, and, in some cases, also on frozen sections. The diagnostic contribution of the demonstration of alpha-fetoprotein, alpha-antitrypsin, hepatitis B surface antigen, carcinoembryonic antigen (CEA), and biliary glycoprotein I (BGPI), compared with routine hematoxylin-eosin and reticulin stains was evaluated. For the differentiation between HCC, adenoma, and focal nodular hyperplasia, immunohistochemistry contributed less than the strict application of histologic criteria. Immunohistochemistry of CEA and BGPI, however, appeared to be of help in differentiating between primary and secondary liver tumors as follows: CEA is consistently absent in liver cell tumors, while a bile canalicular staining pattern was seen in 80% of HCC due to the presence of BGPI reactivity.