Collagen Features of Dermatofibrosarcoma Protuberans Skin Base on Multiphoton Microscopy.

Dermatofibrosarcoma protuberans is a rare, low-grade skin fibroblastic tumor which tends to recur locally due to its high misdiagnosis. Dermatofibrosarcoma protuberans usually spreads through the intracutaneous and subcutaneous layers into the deep dermis layer in which the main component is collagen. Therefore, alterations in collagen shape and content are important for accurate diagnosis of dermatofibrosarcoma protuberans. In this study, multiphoton microscopy was employed to observe normal human skin and dermatofibrosarcoma protuberans skin. Then, a centerline based on an algorithm that skeletonizes a binary image of fibers was applied to analyze collagen shapes in 2 types of skin. Then, collagen content, including intensity and density, was quantitatively obtained to demonstrate differences between the 2 skin types. Results indicate that collagen shape and density can be considered as auxiliary diagnostic parameters to improve the accuracy of dermatofibrosarcoma protuberans diagnosis.

Ultrastructural identification of a proximal tubulopathy without crystals in a relapsed multiple myeloma patient.

A multiple myeloma patient, who had been treated with a hematopoietic stem cell transplant, underwent a renal biopsy for investigation of a possible relapse of disease as indicated by increased serum creatinine and positive urinary Bence-Jones protein containing increased kappa light chain. Paraprotein-related renal disease was not evident by light microscopy or immunofluorescence microscopy however electron microscopy demonstrated a proximal tubulopathy with intracytoplasmic non-crystalline inclusions. The ultrastructural findings suggested possible end-organ involvement by the disease and follow-up studies subsequently revealed a relapsed multiple myeloma in the patient. The case exemplifies the usefulness of electron microscopy in detecting paraproteins that, in some instances, may be difficult to demonstrate by other techniques.

Prognostic Value of a Category Based on Electron Microscopic Features of Clival Chordomas.

OBJECTIVE: Skull base chordomas are clinically malignant because of the difficulty of total removal and the high recurrence rate. Because the disease-free survival after surgery is currently unpredictable, there is a need for new parameters, obtained from histologic analyses of the resection specimen, that allows a risk stratification of patients with chordoma. METHODS: In recent years, electron microscopic diagnoses were introduced into the clinical practice for the diagnosis of chordoma in our department. Clinical outcomes and electron microscopic features were retrospectively reviewed in the study. The electron micrograph shows that clival chordoma can be divided into cell-dense type (CDT) and matrix-rich type (MRT). Of all the patients with chordoma, complete data from 27 patients were obtained. There were 12 patients in the CDT group and 15 patients in the MRT group. The paraffin-embedded tissue samples were stained with Ki-67 antibody. The prognostic values of electron microscopic classification were compared between the 2 groups. RESULTS: There were no statistical differences in the gender (P = 0.704) and age distribution (P = 0.243) between the 2 groups. There was also no statistical difference concerning the constitution of primitive tumors and recurrent tumors between the 2 groups (P = 0.706). The CDT group had a higher mortality rate than the MRT group (P = 0.037). The tumors in the CDT group were prone to recurrence and the need for reoperation within 1 year after surgery, which is statistically different from that in the MRT group (P < 0.001). Chordoma tumors of 23 patients (85.2%) stained positive for Ki-67. CDT chordomas had a higher Ki-67 proliferation index than the MRT chordomas (P = 0.013). CONCLUSIONS: The present study demonstrates the utility of the ultrastructural features in the prognostic outcome of patients with chordoma. According to the ultrastructures of chordomas, they can be divided into CDT and MRT. CDT chordoma cells have a more aggressive proliferative ability. Patients with CDT have a poor prognostic factor in clival chordoma, which has a higher risk of recurrence and a shorter survival.

A strongly CD34-positive meningioma that was difficult to distinguish from a solitary fibrous tumor.

Fibrous or transitional meningioma and solitary fibrous tumor (SFT) are frequently difficult to differentiate from each other on the basis of histopathology. It is extremely unusual for a meningioma to exhibit diffuse, strongly positive immunoreactivity for cluster of differentiation 34 (CD34), and this has never been previously reported from a histopathological specimen. A patient with transitional meningioma that exhibited strongly positive for CD34, which has been regarded as characteristic of SFT and is considered to be useful for distinguishing the latter from meningioma, is reported.

Amelanotic melanoma in a New Zealand White Rabbit (Oryctolagus cuniculus).

A 3.5-year-old intact male double-transgenic New Zealand white rabbit (Oryctolagus cuniculus), apoA-I and LCAT (apolipoprotein and lecithin:cholesterol acyltransferase), was presented with a discrete, raised facial mass (0.5 x 1.0 x 1.0 cm). The mass was surgically excised, with reoccurrence to the same site 88 days later. A second surgical excision was performed, and the rabbit died 3 weeks later from respiratory distress. At necropsy, multiple varying-sized masses were observed in the ventral mandibular region and throughout the lungs, pleura, and diaphragm. On histopathology, the masses were composed of moderately anisocytotic and anisokaryotic polygonal to spindloid cells with moderate finely granular, lightly eosinophilic cytoplasm, having round to oval nuclei with one to several nucleoli and finely stippled chromatin. Mitotic figures were frequent. Lymphatic and venous invasion were noted with neoplastic cells metastasized to the submandibular lymph nodes, lungs, liver, and adventitial surface of the aorta. Fontana-Masson stain was negative for melanin, thereby necessitating immunohistochemistry and transmission electron microscopy. Positive staining with MART-1 (a melanocyte protein marker) combined with transmission electron microscopy revealing type II melanosomes confirmed the diagnosis of an amelanotic melanoma.

Prospective comparison of optic versus blind endoscopic ultrasound in staging esophageal cancer.

BACKGROUND: Esophageal tumours too stenotic to cross with optic endoprobe ultrasound (EUS) may still be staged with the blind endoprobe of 9 mm diameter. The aim of this study was to determine the relative accuracy of both optic and blind endoprobe-defined radiological stages when compared with the histopathological pTN stages. METHODS: Sixty-seven patients [8 squamous cell carcinoma (SCC), 59 adenocarcinoma (ACA)] with tumours too stenotic to allow optic endoprobe assessment underwent blind endoprobe examination and were compared with 146 patients (48 SCC, 98 ACA) undergoing optic endoprobe assessment. The strengths of agreement between the EUS stage and the histopathological stage were determined by the weighted kappa statistic (Kw). RESULTS: Tumour dilatation was required in 3 (2%) of the patients undergoing optic EUS compared with 20 (30%) of the patients undergoing blind EUS (p = 0.0001). Optic EUS T-stage Kw was 0.612 [95% confidence interval (CI) 0.553-0.671, p = 0.0001] compared with 0.530 (0.426-0.634, p = 0.0001) for blind EUS. Optic EUS N-stage Kw was 0.639 (0.576-0.702, p = 0.0001) compared with 0.666 (0.565-0.737, p = 0.0001) for blind EUS. Patients undergoing blind probe EUS were more likely to have advanced tumour stage than patients undergoing optic probe EUS (p = 0.005). CONCLUSIONS: Blind probe EUS facilitated complete radiological staging in 31% of cases that would otherwise have resulted in a designation of failure to cross at EUS, and was as accurate as optic probe EUS in assessing pTN stage.

Malignant transformation of supratentorial clear cell ependymoma.

Recurrence of clear cell ependymoma is not a rare condition, but malignant transformation of clear cell ependymoma has not yet been well presented. The authors report a 44-year-old man who presented with progressive right hemiparesis. A brain tumor in the left frontal premotor area was removed and an initial pathological diagnosis of oligodendroglioma was made. The tumor recurred 4 months later, and reoperation of the tumor and adjuvant local radiotherapy were performed. The patient subsequently underwent surgical removal of recurrent tumors on another four occasions (6 times in total) during a period of 11 years and finally died of the original disease. Histopathological studies of all surgical and autopsy specimens were carried out. The first and second surgical specimens did not contain any ependymal rosettes or pseudorosettes, and thus a diagnosis of oligodendroglioma was made. However, the third surgical specimen showed pseudorosettes. At this time, the tumor had an ultrastructural appearance compatible with ependymoma. Thereafter, the recurrent tumors showed anaplastic features such as nuclear pleomorphisms and necrosis with pseudopallisading. The autopsy specimens resembled a feature of glioblastoma but the tumor was sharply demarcated from the surrounding parenchyma.

Ultrastructure in resolving a diagnosis of poorly differentiated clear cell sarcoma of soft parts in an adolescent male.

Clear cell sarcoma of soft parts is a rare tumor in children and it requires a high index of suspicion for accurate diagnosis. Early diagnosis leads to radical surgical excision and limits the aggressive behavior of this tumor. We report a case of a 12-year-old boy with a recurrent soft-tissue tumor in the scalp, misdiagnosed on three occasions as epitheloid sarcoma owing to the poorly differentiated appearance of cells. In spite of focal S-100 expression, this tumor was not recognized as a tumor of melanocytic origin till melanosomes were demonstrated on electron microscopy (EM). Detection of melanosomes on electron microscopy helped in clinching the histology diagnosis, reiterating the definite role of EM in diagnosing these tumors. Failure to accurately diagnose this tumor resulted in institution of preoperative chemotherapy, delayed surgical excision, tumor progression and death of patient within a year and half of presentation.

Low-grade abdominopelvic sarcoma with myofibroblastic features (low-grade myofibroblastic sarcoma): clinicopathological, immunohistochemical, molecular genetic and ultrastructural study of two cases with literature review.

AIMS: Low-grade myofibroblastic sarcoma (LGMS) represents a rare soft tissue neoplasm with a predilection for the head and neck. Intra-abdominal LGMS are rare with only four unequivocal examples reported so far. Two further cases in females in their 60s and 70s are analysed here. METHODS: Immunohistochemical stains were applied on fresh-cut sections using the avidin-biotin complex method and the following antibodies: vimentin, alpha-SMA, desmin, h-caldesmon, S-100, CD117, CD34, fibronectin, HMB45, Pan-keratin, Ki-67, beta-catenin, MDM2, PDGFRalpha, PDGFRbeta and ALK-1. Genomic DNA was isolated from microdissected formalin-fixed paraffin-embedded tumour tissue and examined for KIT and PDGFRA mutations by PCR and direct sequencing of KIT and PDGFRA. Ultrastructural studies were also performed. RESULTS: The tumours arose in the mesentery and the pelvic peritoneum. Both revealed features intermediate between conventional fibrosarcoma and leiomyosarcoma with fascicles of spindled, stellated or plump cells possessing fusiform indented vesicular nuclei and pale eosinophilic cytoplasm. Mitotic activity ranged from 1 to 15 per 10 HPFs. The tumour cells strongly expressed vimentin, variably alpha-smooth muscle actin and fibronectin, but were negative for CD117, S-100, desmin, h-caldesmon, beta-catenin, ALK-1, MDM2, PDGFRalpha and PDGFRbeta. One tumour showed a weak expression of CD34. Molecular analysis revealed a wild-type KIT, exons 9, 11 and 13, and PDGFRA, exons 12 and 18. The patients developed multiple peritoneal recurrences at 5, 13 and 25 months, and 10, 19, 25 and 32 months, and were alive at 25 and 32 months, respectively. Distant metastases were not detected. CONCLUSION: Abdominopelvic LGMS follows a more aggressive clinical course characterised by a higher propensity for local recurrence, contrasting their more superficially located counterparts. LGMS may mimic a variety of benign and low-grade malignant neoplasms and might be under-recognised.

Spontaneous regression of recurrent and metastatic Merkel cell carcinoma.

Merkel cell carcinoma (MCC) is a malignant neuroendocrine tumor with a high rate of recurrence and metastasis. Despite its high degree of malignancy, spontaneous regression has been documented. We report an 87-year-old woman who presented with recurrent MCC on her left cheek and regional lymph node metastasis. Although she received no treatment due to her poor condition, the recurrent metastatic lesion regressed spontaneously within 2 months.

[Laryngectomy as a salvage procedure of the patients with massive postradiation injury of the larynx]. / Laryngektomia jako postepowanie ratujace u chorych z nasilonym odczynem popromiennym po radioterapii raka krtani.

INTRODUCTION: Author discusses problems and treatment principles of patients with massive postradiation injury, who had laryngectomy procedure as a result of insufficience of the farmacological treatment. MATERIAL AND METHODS: There were 12 patients who were performed laryngectomy as a treatment of massive postradiation injury of the larynx in the period 1975-2005. We suspected presence of persistent neoplasm with postradiation changes. Seven laryngectomies were performed after confirmation of the neoplasm in 1-3 biopsies. Three patients were treated operatively without this confirmation in spite of two biopsies which were negatively, and two patients were treated in this way without biopsies. RESULTS: Two patients had tomour free postlaryngectomy specimens in the histopathological examinations, and among 10 others the reccurence of the tumour after radiotherapy was present during the post-laryngectomy histopathological examinations. In 7 cases this reccurence was proved with massive postradiation injury in endoscopic biopsies before laryngectomy. DISCUSSION: Author presents his own problems and presents methods of treatment of the patients with massive postradiation injury of the larynx described in literature.

Olfactory neuroepithelioma: an immunohistochemical and ultrastructural study.

Three cases of olfactory neuroepithelioma are presented in this report. Histologically, these tumors were composed of small cells with round to oval, relatively hyperchromatic nuclei and scanty cytoplasm. The tumor cells were occasionally observed in tubular formations or rosette-like arrangements. Immunohistochemically, the tumor cells showed a positive reaction for cytokeratin AE1, cytokeratin CAM5.2, Ber-EP4, antisynaptophysin and anti-S100 protein in all cases. In two cases, LH-RH was detected in the tumor cells. Ultrastructurally, the tumor cells had the differentiation features of olfactory epithelium. Olfactory neuroepithelioma is a rare occurrence and it can be very difficult to distinguish olfactory neuroepithelioma from small cell carcinoma, neuroendocrine carcinoma and so-called "olfactory neuroblastoma" on the basis of hematoxylin and eosin stained sections alone. In controversial cases, a diagnosis of olfactory neuroepithelioma must be substantiated by ultrastructural and immunohistochemical findings, particularly regarding the detection of Ber-EP4 and LH-RH immunoreactivity.

Novel use of ultrasound-guided surface marking of head and neck tumors invading facial skin.

Malignant tumors of deep head and neck structures can invade skin, but the tumor periphery is difficult to assess clinically. The surgeon's dilemma is achieving tumor clearance with safe margins while at the same time minimizing skin loss on the face. We show, in 2 cases involving the face, that high-resolution diagnostic ultrasound was superior to CT scan in demonstrating the periphery of the tumor. The tumor was distinguished from surrounding edema by its lower echogenicity and homogeneous echotexture. The maximum contour of the tumor was marked on the skin surface with ink under ultrasound guidance. The ink marking aided excision and reconstruction planning. Subsequent histology showed the surgical margins were clear of tumor. The patients remained tumor-free for more than 3 years. Ultrasound imaging therefore shows good potential for planning surgical resection with a safe margin and for aiding decisions on donor site and type of flap for reconstruction.

Metastatic small cell malignant melanoma: a case requiring immunoelectronmicroscopy for the demonstration of lattice-deficient melanosomes.

A case of metastatic malignant melanoma exhibiting small cell morphology is described. The patient had had a previous primary nodular small cell melanoma. The metastatic tumor was examined by conventional histology, light microscope immunohistochemistry, conventional electron microscopy, and ultrastructural immunolabeling. It consisted of small cells, which, however, varied in size and were present in distinct but merging areas. Tumor cells were negative for S-100 protein and very focally positive for cytokeratin: these findings in combination with small cell morphology suggested the possibility of small cell carcinoma. However, other melanocytic markers were positive. Neuroendocrine markers were negative. By electron microscopy, tumor cells lacked unambiguous melanosomes but contained paranuclear aggregates of nondescript granules. Following ultrastructural immunolabeling, these were found to be decorated with gold-labeled HMB-45 antibodies, thereby confirming them as lattice-deficient melanosomes. This tumor is an uncommon example of malignant melanoma where immunoultrastructural analysis helped clarify the nature of otherwise nondescript granules as true but lattice-deficient melanosomes. This is also the first case of small cell melanoma to be studied by electron microscopy.

Carcinoid-like pattern in sebaceous neoplasms: another distinctive, previously unrecognized pattern in extraocular sebaceous carcinoma and sebaceoma.

This report emphasizes a carcinoid-like pattern, a previously unrecognized feature in cutaneous sebaceous neoplasms. We report 7 patients with sebaceous tumors in which neoplastic cells were arranged in a trabecular and ribbon-like pattern or formed rosettes/pseudorosettes. The cases included 6 men and 1 woman, with their ages at the diagnosis ranging from 43 to 87 years (median age, 59). All patients presented with a solitary lesion. Locations were the scalp (n = 6) and forearm (n = 1). The carcinoid-like arrangement of neoplastic cells was the sole pattern in 4 cases, and in 3 cases the so-called labyrinthine/sinusoidal and/or rippled patterns were seen in addition. Sebaceous differentiation in the form of mature sebocytes varied from almost none to approximately 10%. Although the neoplasm appeared benign architecturally, the presence of cytologic atypia qualified 2 tumors as low-grade carcinomas. Four lesions represented sebaceomas, and in 1 case microscopic delineation between a carcinoma and sebaceoma was difficult. No neuroendocrine differentiation was demonstrated immunohistochemically, histochemically, and ultrastructurally. Electron microscopic examination performed in 1 case of carcinoma revealed lipid vacuoles in a minority of cells. There were no membrane-bound neuroendocrine granules. Rare cells contained peculiar large helioid inclusions. We conclude that the carcinoid-like pattern is another distinctive pattern indicative of sebaceous neoplasms. This pattern seems to be closely related to the rippled and labyrinthine/sinusoidal patterns, as exemplified by our cases, in which these arrangements sometimes occurred simultaneously.

Spindle cell oncocytoma of the adenohypophysis: report of two recurrent cases.

The recently described "spindle cell oncocytoma of the adenohypophysis" is a very rare and often misdiagnosed entity. A benign biologic behavior has been suggested based on the absence of recurrences with a median follow-up of 3 years. Herein, we present 2 cases of recurrent spindle cell oncocytomas. One patient is a 71-year-old woman (case no. 1) and the other a 76-year-old man (case no. 2). Recently, both underwent transsphenoidal reexploration for recurrent "pituitary adenoma." Patient no. 1 had initial surgery 11 years ago with a recurrence after 3 years that was initially stable. Ultimately, a partial resection was performed after compression of optic pathways by the tumor, and approximately 1 year later, re-resection was carried out. Patient no. 2 had initial surgery 10 years ago with recurrence and resection after 3 years. He recently presented with a large mass that involved the pituitary fossa and base of the skull, with extension into the nasopharynx and nasal cavity. The primary and recurrent lesions of both cases showed similar architecture with interlacing fascicles of spindle cells that alternated with areas of epithelioid-like cells that exhibited eosinophilic, granular cytoplasm. Neoplastic cells were positive for vimentin, S-100 protein, and epithelial membrane antigen, and negative for glial fibrillary acidic protein, chromogranin, and pituitary hormones. Increased mitotic activity was noted in 1 lesion (case no. 2), although both cases had high Ki-67 indices (18% and 20%, respectively). The ultrastructural features of both cases were characteristic with intracytoplasmic accumulations of large mitochondria. The histopathologic features of these lesions are consistent with spindle cell oncocytoma of the adenohypophysis. In summary, we are reporting 2 cases of recurrent spindle cell oncocytoma of adenohypophysis with longer follow-up than previously published cases, suggesting the possibility of a more aggressive behavior than has been initially considered.

Histochemical and ultrastructural study of an elastofibroma dorsi coexisting with a high grade spindle cell sarcoma.

Elastofibroma dorsi is a pseudotumoral fibroproliferative lesion characterized by polymorphic fiber-like deposits of elastinophilic material. Several theories have been reported explaining the pathogenesis of elastofibroma. Recent cytogenetic studies have demonstrated chromosomal instability in elastofibromas, not normally observed in non-neoplastic tissues. These chromosomal defects are commonly observed in aggressive fibromatosis too. Such clinical observations suggest a multistage pathogenetic mechanism for the onset of elastofibroma. This study, using histochemical, immunohistochemical staining techniques, and ultrastructural examination, describes the detection of an otherwise typical elastofibroma contextual to a high grade sarcoma. Hence, the coexistence of elastofibroma and high-grade sarcoma may suggest a causal link between the two pathological entities. The results obtained suggest that the coexistence of the two pathological entities is conceivably coincidental.

Gangliocytic paraganglioma of the bronchus: a case report with follow-up and ultrastructural assessment.

We report a case of gangliocytic paraganglioma of bronchus. A 54-year-old woman underwent bronchoscopy following two episodes of right lower lobe pneumonia over the previous 5 months with unresolved chest radiographic changes. A computerized tomographic scan showed a right lower lobe endobronchial lesion, and at bronchoscopy there was a mass partly occluding the lumen of the bronchus. The biopsy and subsequent bronchoscopic resection showed a tumor with morphologic, immunohistochemical, and ultrastructural features of paragangliomatous, gangliocytic, and Schwann cell differentiation consistent with a gangliocytic paraganglioma. The lesion was treated conservatively with bronchoscopic resection and laser therapy. Histopathologic examination of recurrent tumor at 6 months showed features consistent with paraganglioma. Ten months after initial diagnosis, there was no bronchoscopic evidence of residual tumor. The occurrence of gangliocytic paraganglioma in diverse sites gives cause for the reappraisal of the histogenesis of this fascinating lesion. The variable morphology of this lesion may be an expression of the potential for divergent differentiation of a pluripotent stem cell.

Predictive variables for the biological behaviour of basal cell carcinoma of the face: relevance of morphometry of the nuclei.

We did a morphometric analysis of 130 histological sections of basal cell carcinoma (BCC) of the face to find out whether morphometric variables in the structure of the nuclei of BCC cells could serve as predictors of the biological behaviour. We considered the following variables: maximum and minimum diameters, perimeter, nuclear area and five form factors that characterise and quantify the shape of a structure (axis ratio, shape factor, nuclear contour index, nuclear roundness and circumference ratio). We did a statistical analysis of primary and recurring tumours and four histology-based groups (multifocal superficial BCCs, nodular BCCs, sclerosing BCCs and miscellaneous forms) using a two-sided t test for independent samples. Multifocal superficial BCCs showed significantly smaller values for the directly measured variables (maximum and minimum diameters, perimeter and nuclear area). Morphometry could not distinguish between primary and recurring tumours.