Hepatectomy After Yttrium-90 (Y90) Radioembolization-Induced Liver Fibrosis.

An obese 55-year-old woman with nonalcoholic fatty liver disease presented 7 years after resection of a T3N1 ileal carcinoid tumor with an elevated chromogranin A, multifocal metastatic disease to the liver, and carcinoid syndrome. She underwent right hepatic artery yttrium-90 (Y90) radioembolization, followed a month later by selective Y90 treatment to segment IV. She then presented to our clinic 10 months later, remaining symptomatic with flushing, diarrhea, anxiety, myalgia, pain, and persistent night sweats despite Sandostatin administration. At least 11 tumors were identified in the right lobe of the liver and three in segment IV on liver-specific imaging. These lesions were stable over a year with no new lesions. At exploration, there was marked hypertrophy of the left lateral segment due to the yttrium-90 treatment of segments IV-VIII, corresponding with preoperative volumetrics predicting a functional liver remnant (FLR) of 40% after extended right hepatectomy. The right lobe and segment IV were fibrotic, hard, and visibly damaged. The gland had a thick, fibrotic capsule, and the parenchyma was dense, inflexible, and difficult to dissect, consistent with the previously reported morbidity of these operations. Extended right hepatectomy was performed. Final pathology demonstrated 15 foci of metastatic well-differentiated neuroendocrine carcinoma that were negative for necrosis, as was expected given her continued symptoms despite radioembolization. Numerous amorphous spheres, frequently in clusters, were present in segments IV-VIII in vessels and approximating tumors consistent with prior Y90 radioembolization. The patient had an uneventful post-operative recovery and remains symptom free on follow-up. Treatment options for metastatic tumors to the liver have increased in recent years and currently include radioembolization in selected patients. Surgical cytoreduction and complete metastasectomy continue to offer improvement in symptoms, quality of life, and survival in patients with neuroendocrine liver metastases; however, hepatectomy after radioembolization is unique and carries increased morbidity/mortality, likely due to Y90-induced liver fibrosis. We demonstrate images of fibrotic yttrium-90 radiation-affected liver and histological sections of radioembolic microbeads in blood vessels and distributed around resected tumors.

Benign adrenal hemangiomas may mimic metastases on PET.

CT or MRI are utilized in the initial evaluation of adrenal incidentalomas; however, overlap exists between benign and malignant lesions on these examinations. The American College of Radiology recommends PET scans to complement CT and MRI for patients with adrenal masses and a moderate-to-high likelihood of neoplastic disease. We present images of a PET-avid adrenal lesion in a patient with pulmonary and pancreatic neoplasms that mimicked metastasis, but was found to be a benign adrenal hemangioma on surgical resection. The use of PET for adrenal tumors, specifically adrenal hemangiomas, will be reviewed.

Survival after resection of cutaneous adnexal carcinomas with eccrine differentiation: risk factors and trends in outcomes.

BACKGROUND: Current staging systems do not specifically address cutaneous adnexal carcinomas with eccrine differentiation. Due to their rarity, prognosis and management strategies are not well established. A population-based study was performed to determine prognostic factors and survival. METHODS: Patients diagnosed with cutaneous adnexal carcinomas with eccrine differentiation were identified using the surveillance, epidemiology, and end results population-based cancer registry. Associations between risk factors, treatment modalities, and survival were calculated using logistical regression, Kaplan-Meier estimates and log-rank analysis. RESULTS: The incidence of distinct eccrine subtypes was determined within 1,045 patients with cutaneous adnexal tumors containing eccrine differentiation. All-cause 5-year survival (OS) was 82%, while age-adjusted survival was 94%. Patients with microcystic adnexal carcinoma had improved OS (90%) compared to patients with hidradenocarcinoma (74%), spiradenocarcinoma (77%), porocarcinoma (79%), and eccrine adenocarcinoma (81%). The majority of patients were treated with surgical excision and a small subset with surgery plus radiation, with similar OS. Patients with well-to-moderately differentiated tumors demonstrated improved OS compared to those with poorly differentiated/anaplastic disease. CONCLUSIONS: Histological subtype and grade were associated with survival, and should be specified in biopsies and excised specimens. Surgical excision is appropriate, and the addition of adjuvant radiation may not be associated with survival. These results highlight survival data and high-risk prognostic factors that warrant prospective validation, and may augment current staging systems.

Mucormycosis infection of the lacrimal sac.

Biopsy of the lacrimal sac for patients with primary acquired nasolacrimal duct obstruction has been a topic of debate for many years. The authors present a case of a 72-year-old immunocompetent woman with a 2-month history of epiphora secondary to nasolacrimal duct obstruction. During an uneventful dacryorhinocystostomy, a routine lacrimal sac biopsy was performed and revealed mucormycosis. After appropriate infectious disease consultation, intensive antifungal therapy was given uneventfully. The patient has not had any signs of active Mucor infection after treatment in 6 months of follow up. This case demonstrates the utility of routine lacrimal sac biopsy and stands as an example of the potential to miss a serious diagnosis.

Caseating granulomata caused by hemostatic agent posing as metastatic leiomyosarcoma.

BACKGROUND: As the number of minimally invasive and laparoscopic procedures increases, hemostatic agents are becoming more popular as a means of achieving rapid hemostasis. CASE REPORT: The patient is a 61-year-old woman who underwent a laparoscopic supracervical hysterectomy. FloSeal Hemostatic Matrix (Baxter Healthcare, Deerfield Illinois) was used at the conclusion of the procedure. RESULTS: Pathology unexpectedly revealed high-grade leiomyosarcoma of the uterus. The patient then presented to our facility for consultation and was scheduled for robotic trachelectomy and lymphadenectomy. Laparoscopy revealed nodular lesions throughout the abdomen and pelvis. Biopsies were performed and the case aborted. Final pathology however showed caseating foreign body giant cell granulomata in all specimens. No malignancy was found. The patient then underwent exploratory laparotomy, trachelectomy, and a staging procedure. All pathology specimens and pelvic washings were negative for malignancy. CONCLUSIONS: Use of gelatin-thrombin hemostatic agents may elicit a foreign body reaction leading to large giant cell granulomata. In this case, the presence of these granulomata mimicked metastatic disease.

Histologically pure stage I seminoma with an elevated beta-hCG of 4497 IU/l.

Approximately 30% of patients with pure seminoma of the testis have mild elevation of human chorionic gonadotropin (hCG) due to the presence of syncytiotrophoblastic giant cells. Levels are usually less than 500 IU/L; however, the occurrence of higher levels is rare. We report a case of a man with a stage I histologically pure seminoma, copious syncytiotrophoblast cells, and a serum beta human chorionic gonadotropin (beta-hCG) of 4497 IU/L. To our knowledge this is the third highest value of beta-hCG reported with a stage I pure seminoma. The patient underwent an orchiectomy and chemotherapy. His beta-hCG level was undetectable by postoperative day 13, and he remains disease free at 30 months.

Stereotactic core needle biopsy of nonpalpable breast lesions using a conventional mammography unit with an add-on device.

OBJECTIVE: The purpose of this prospective study was to assess the accuracy of an add-on stereotactic unit for core needle biopsy of mammographic lesions. SUBJECTS AND METHODS. Between September 1994 and February 2001, 506 stereotactic core needle biopsies of mammographic lesions in 492 patients were performed in our center on a mammography unit with add-on stereotactic equipment. Of the initial 92 patients, 80 underwent stereotactic core needle biopsy and surgical excision simultaneously. In subsequent cases, surgical biopsy was performed after core biopsy in patients who had malignant or atypical histologic results or discordance between mammographic and pathologic findings. Follow-up mammography was advised for all patients whose core biopsy results were diagnosed as benign lesions. RESULTS: Histologic results for 506 lesions undergoing stereotactic core needle biopsy were as follows: 113 (22.3%) were malignant; 369 (72.9%), benign; and 24 (4.7%), atypical. Of 113 malignant lesions identified at stereotactic core needle biopsy, 111 were confirmed as malignant, whereas two showed no evidence of malignancy at surgical excision. Of 369 lesions diagnosed as benign at stereotactic core needle biopsy, 172 (46.6%) showed no change on follow-up mammography, 114 (30.9%) were lost to follow-up, and 83 (22%) underwent surgical excision. Of 24 lesions with atypical histology, 23 had surgical follow-up, six were malignant, nine were benign, and eight were confirmed as showing atypical histology. Stereotactic core needle biopsy of the 506 lesions was complicated by five (1.0%) cases of vasovagal attack and four (0.8%) cases of bleeding. The resulting sensitivity, specificity, and positive and negative predictive values were 98.3%, 93.0%, 86.0%, and 99.2% respectively. CONCLUSION: Biopsy with an add-on unit is safe, reliable, accurate, and cost-effective with results comparable to those reported for dedicated prone biopsy devices.

Misdiagnosis of high-grade vulvar intraepithelial neoplasia (VIN III) as mild cervical intraepithelial neoplasia (CIN I) on Papanicolaou tests.

CONTEXT: Although high-grade vulvar intraepithelial neoplasia (VIN III) is a clinically significant lesion, it can be overlooked because of nonspecific clinical findings and the fact that its cytomorphologic features mimic those of mild cervical intraepithelial neoplasia (CIN I). OBJECTIVE: To determine if there are cytomorphologic features on Papanicolaou tests that can reliably distinguish between VIN III and CIN I. DESIGN: Papanicolaou tests diagnosed as CIN I from patients with biopsy-proven CIN I were compared with Papanicolaou tests diagnosed as CIN I from patients with biopsy-proven VIN III but with no biopsy-proven CIN I. RESULTS: None of the cytomorphologic features evaluated could reliably distinguish CIN I from VIN III. CONCLUSION: Since the Papanicolaou test cannot be used to distinguish between CIN I and VIN III, the clinician must pay careful attention to the clinical and colposcopic findings. Further research evaluating the use of ancillary studies, such as human papillomavirus typing, may be useful.