Pulmonary arteriovenous malformation complicating coccidioidal pneumonia.

A patient was treated for lobar pneumonia due to coccidioidomycosis. When the pneumonia recurred, the patient was found to have an arteriovenous malformation, which had become infected. Complete resolution was achieved with resection and postoperative amphotericin B therapy.

Exuberant local tissue reaction to intramuscular injection of nandrolone decanoate (Deca-Durabolin)--a steroid compound in a sesame seed oil base--mimicking soft tissue malignant tumors: a case report and review of the literature.

We present an unusual pseudotumor that formed in reaction to self-administered intramuscular injections of an anabolic steroid, nandrolone decanoate (Deca-Durabolin) in a young soldier. The histopathologic features which closely mimicked several malignant neoplasms could have led to an incorrect diagnosis of malignancy and unnecessary extensive surgery. To our knowledge, this phenomenon has not been previously reported.

Complex cryptococcal empyema.

Cryptococcus neoformans continues to present diagnostic and treatment challenges in patients with underlying malignant neoplasms. Cryptococcal empyema is a relatively rare complication of cryptococcal disease. It is important to distinguish whether uncontrolled malignancy or cryptococcal infection is responsible for the effusion. We used traditional diagnostic approaches, bronchoscopy and transthoracic fine needle aspiration, to verify the presence of the organism but continued to have treatment failure until adequate drainage was established.

Biochemical values, complement levels, and hemostatic data in septic leukoerythroblastosis.

Recently, the association of granulocytic fragments on blood smear with leukoerythroblastosis in sepsis has been identified in nine patients. Granulocytic fragments were identified by both light and electron microscopy as well as cytochemistry. Leukoerythroblastosis is a poorly defined, uncommon syndrome with leukocytosis, left shift, and nucleated red blood cells (nRBCs) disproportionate to the degree of anemia, which may be associated with leukemia or neoplasia in the bone marrow, acute infection, hemolysis, myelofibrosis, or miscellaneous causes. Here a subgroup with high white blood cells (WBC) and acute infection was studied. The corrected WBC for nine patients was 40 x 10(9) per L with 33 nRBC per 100 WBC; serum C3 and C4 levels before and after the development of leukoerythroblastosis were 0.6 +/- 2 g per L; 0.18 +/- 0.04 g per L pre-leukoerythroblastosis and 0.7 +/- 0.46 g per L; 0.30 +/- 0.27 g per L post-leukoerythroblastosis, respectively, in four patients. The platelet count, prothrombin time (PT), and activated partial prothrombin time (aPTT) were 133 x 10(9) per L, 24.4 sec., and 53.5 sec., respectively, for nine patients. Multiphasic chemistries at the time of leukoerythroblastosis were measured in five patients; abnormal values included calcium of 2.0 +/- 0.4 mmol per L, creatinine of 336 +/- 130 mumol per L, total protein of 45 +/- 17 g per L, albumin of 27 +/- 11 g per L, total bilirubin of 421 +/- 362 mumol per L, uric acid of 499 +/- 264 mumol per L, triglycerides of 4.9 +/- 3.7 mmol per L, and alkaline phosphatase of 3.5 +/- 1.0 mu kat per L.(ABSTRACT TRUNCATED AT 250 WORDS)

Malignant fibrous histiocytoma and malignant melanoma: the role of immunohistochemistry and electron microscopy in the differential diagnosis.

Malignant fibrous histiocytoma (MFH) and malignant melanoma (MM) occur together often in the differential diagnosis of poorly differentiated neoplasms. They differ, however, in their biologic behavior and recommended treatment. Investigators have therefore explored a variety of special techniques, including electron microscopy (EM) and immunoperoxidase (IP), to classify these tumors accurately and to separate them from each other. To determine the usefulness of IP and EM in the classification of these tumors, we applied a Fontana-Masson stain and IP probes for vimentin, alpha-1-antitrypsin (alpha-1-A), human melanoma black (HMB)-45, and S-100 protein to twelve MMs and nine MFHs, all of which had available EM studies. Three of twelve MMs were amelanotic. All tumors contained vimentin. Eight of twelve MMs and six of nine MFHs contained alpha-1-A. Ten of twelve MMs and no MFHs contained HMB-45. Eleven of twelve MMs and, surprisingly, two of nine tumors classified by light and EM as MFHs contained S-100 protein. When problems arose with either IP negativity or potentially misleading cross-reactivity, careful EM study allowed definitive classification.

Granulocytic fragments in sepsis.

We report here three patients with sepsis and one with acute pancreatitis and possible sepsis who developed granulocytic fragments on blood smears obtained prior to death. In case 1, these fragments were identified cytochemically. In case 3, granulocytic cytoplasmic projections and fragments were identified by electron microscopy of the buffy coat. All patients had leukerythroblastosis. The average corrected white blood count (WBC) was 46 X 10(9)/liter with 34 nucleated red blood cells (nRBC)/100 WBC. Patient 1 had thrombocytosis whereas patients 2, 3, and 4 were thrombocytopenic. Terminal complement levels were decreased in patients 3 and 4 as previously noted in sepsis (Sprung CL, Shultz DR, Marcial E, et al.: Complement activation in septic shock patients. Crit Care Med 14:525, 1986). A general correlation between nRBC and granulocytic fragments/100 hpf (high power field) was observed in patients 3 and 4. Granulocytic fragments were not identified on the blood smears of several patients with leukemoid reactions without erythroblastosis. Although the precise etiology of these fragments is unclear, we believe their recognition is important because all patients died within 32 hours after granulocytic fragments were identified. Furthermore, these fragments can falsely elevate the platelet count. Although myeloid fragments have previously been noted in leukemia and lymphoma, this is the first report of their association with conditions unrelated to hematologic neoplasms. These fragments can easily be recognized by careful examination of the blood smear and represent a newly recognized aspect of the septic shock syndrome.

An ultrastructural and light microscopic study of the synovium in ochronotic arthropathy.

The synovium in two well-documented cases of alkaptonuric ochronosis was studied by transmission electron and light microscopy. A feature of alkaptonuria previously unreported in the English-language literature was the presence of phagocytosis of large collagen fibrils by synovial macrophages in both cases. The origin of these fibrils appeared to have been shards of ochronotic cartilage and areas of metaplastic cartilage. This finding suggests that active remodeling of the synovial tissues occurs in advanced ochronotic arthropathy. Numerous shards of ochronotic cartilage were embedded in the synovium. In addition, small aggregates of large collagen fibrils encrusted with apparent ochronotic pigment were occasionally noted in the interstitium. These aggregates of ochronotic collagen are best described as microshards, and they have not generally been recognized in the literature. What appeared by light microscopy to represent ochronotic pigment deposition in interstitial collagen actually represented embedded microshards of ochronotic cartilage in the interstitium. Slender and elongated microshards were most likely to be confused by light microscopy as ochronotic interstitial collagen.

The natural history of gastric cancer and prognostic factors influencing survival.

This study of 783 patients with histologically confirmed gastric carcinoma has confirmed the importance of several previously recognized patient- and tumor-related characteristics related to prognosis and identified some new ones. Of the tumor-related factors, the ones that showed the strongest relationship to survival following curative gastric resection were tumor stage, histologic type, breach of lymph-node capsule, sinus histiocytosis, and gross appearance. Of the tumor- and patient-related factors, the ones that showed the strongest relationship to survival from time of diagnosis of surgically noncurable disease were status of primary, liver metastasis, serum bilirubin level, ascites, extent of tumor burden, and weight loss. The effect of treatment with 5-fluorouracil (5-FU) on survival duration was at best only minimal. Only those patients who received two or more cycles of 5-FU therapy had survival advantage over the remaining patients. The use of regression analysis has made it possible to make predictions of the prognosis of the patients. These predictions could be used in future studies to determine comparability of prognosis of various groups included in different studies and different arms of a randomized study.

Primary lymphomas and sarcomas of the stomach.

The records of patients with primary gastric lymphoma and sarcoma treated at M. D. Anderson Hospital and Tumor Institute between 1945 and 1975 were reviewed. Weight loss, abdominal pain, nausea, and vomiting were the most common presenting symptoms, while palpable abdominal mass was the most common sign. The lymphomas were predominantly located in the distal portion of the stomach, in contrast to the sarcomas, which were commonly located in the body and the proximal portion of stomach. Curative gastric resection was performed in 96% of patients with lymphoma and in 67% of patients with sarcoma. Diffuse histiocytic lymphoma and leiomyosarcoma were the most common histologic types. Patients with lymphoma survived significantly longer than patients with sarcoma (median 75 vs 22 months, P = 0.009). Adjuvant radiotherapy seemed to improve the survival of patients with lymphoma, while curative gastric resection provided the only hope for long-term survival for patients with gastric sarcoma. The place of adjuvant chemotherapy after curative resection of gastric lymphoma and sarcoma remains to be investigated.

Sarcoma of the stomach: clinicopathologic study of 43 cases.

The records of 43 patients with histologically proved primary gastric sarcoma treated at M. D. Anderson Hospital and Tumor Institute between 1945 and 1975 were reviewed. Weight loss, abdominal pain, and hematemesis or melena were the most common symptoms, and palpable epigastric mass was the most common physical sign. Ninety-five percent of the gastric tumors were leiomyosarcomas. The median survival time and the five-year survival for the 29 patients who had curative gastrectomy were 33 months and 38%, respectively. Morphologic and histologic factors that adversely influenced the length of disease-free interval and survival following curative surgery included 1) primary tumor 8 cm or greater in diameter, 2) tumor extension to serosa of the stomach, and 3) low grade of differentiation of the primary tumor. Seventy-seven percent of recurrences in patients with curative tumor resection occurred within two years of resection of the primary. Of the 17 patients with advanced disease who received chemotherapy, two (15%) had objective tumor regression of greater a median survival time of eight months for patients who failed to respond. New approaches that may improve the results of treatment of gastric sarcoma are discussed.

Gastric carcinoma in young adults.

The clinical and pathologic characteristics of gastric carcinoma in patients younger than 30 are compared with those of patients 30 to 39 years of age. Patients in both age groups had similar symptoms, predominantly undifferentiated neoplasms, and poor prognoses. In both groups, there were significant delays in initiation of definitive treatment because of delays in diagnosis. In 80% of the patients, the malignancy extended beyond the stomach wall at diagnosis, adversely affecting their long-term survival. The 20% five year survival in both groups indicates the necessity of early diagnosis and aggressive treatment.

Chemotherapy for sarcoma of the stomach.

The results of chemotherapy for patients with advanced leiomyosarcoma of gastric origin were analyzed. A total of 23 single-agent and multi-drug regimens were given to 17 patients. DTIC and adriamycin (ADR) were the most commonly used chemotherapeutic agents. ADR was used alone or in combination in 13 patients, resulting in partial responses in two patients and disease stabilization in seven. One of the partial responses was obtained with the ADR-DTIC combination and the other was obtained with the cyclophosphamide-vincristine-ADR-DTIC combination. The survival duration for the responders was significantly longer than that obtained for those patients who had disease stabilization or progression. The results of the study show that leiomyosarcoma of gastric origin is less sensitive to chemotherapeutic agents than leiomyosarcomas of other sites, as reported in the literature. New approaches based on the natural history of the disease and with potential to improve the results of treatment of gastrointestinal sarcomas are indicated.

Immunomorphological features of prognostic significance in Dukes' Class B colorectal carcinoma.

Histological slides of primary tumors and regional lymph nodes from 134 unselected patients operated on for colorectal carcinoma of Dukes' Class B were assessed semiquantitatively for the presence of perivascular lymphocyte cuffing in the muscular layers and pericolic/subserosal fat immediately subjacent to the tumors and for paracortical hyperplasia in the regional lymph nodes. These two immunomorphological features related significantly to each other (p less than 0.05), and their combined presence related signifcantly to favorable disease-free interval (p = 0.02) and to survival (p = 0.04), making possible the identification of a subgroup of approximately one-third of Dukes' B class patients with an estimated better than 85% chance for 5-year recurrence-free survival.

Prognostic significance of vascular invasion in colorectal cancer of Dukes' B class.

To further characterize important prognostic factors in colorectal cancer of the Dukes' B class the pathologic material from 143 Dukes' B patients was reviewed for the presence of lymphatic and/or blood vessel invasion and correlated with the postoperative tumor-free interval and overall length of survival. In 27 patients with vascular invasion within the bowel wall, both the tumor-free interval and the overall survival time were not significantly different from the same parameters in 116 patients without vascular invasion (P = 0.28, P = 0.12 respectively). These data suggest that vascular invasion within the bowel wall per se is not an important prognostic factor among patients with colorectal cancer of the Dukes' B class.

Prolongation of postoperative disease-free interval and survival in human colorectal cancer by B.C.G. or B.C.G. plus 5-fluorouracil.

83 patients with colorectal carcinoma of the Dukes' C class were randomised to receive postoperative adjuvant therapy with B.C.G. alone or in combination with oral doses of 5-fluorouracil (5-F.U.), and have been followed for up to thirty months. Results were compared with carefully selected historical controls who were treated by surgery alone. A statistically significant prolongation of both disease-free interval and overall survival was observed in 50 patients receiving the combination of B.C.G. and 5-F.U. (P=0.03, P=0.01 respectively) as well as in 33 patients receiving B.C.G. alone (P=0.03, P=0.05 respectively). The efficacy of B.C.G.+5-F.U. was independent of the number of tumour-involved lymph-nodes in the surgical specimen. In contrast, B.C.G. given alone appears to be highly effective among 10 patients with 6 or more positive lymph-nodes (P less than 0.04) and ineffective (as yet) among 23 patients with 5 or less positive lymph-nodes. These results suggest that adjuvant immunotherapy, with or without chemotherapy, can improve the prognosis of surgically treated patients with colorectal carcinoma of the Dukes' C class.

Adjuvant immunotherapy and chemoimmunotherapy in colorectal cancer of the Dukes' C classification. Preliminary clinical results.

Fifty-eight patients with Dukes' C classification of carcinoma of the large bowel were placed on adjuvant immuno- or chemoimmunotherapy with Bacillus calmette guerin (BCG) or combination of 5-fluorouracil (5-FU) plus BCG following primary and definitive surgery, and were followed for up to 21 months. Of twenty-six patients receiving BCG alone by scarification, five have relapsed with 75% of freedom from disease estimated at 15.1 months compared with 10.1 months in a group of carefully selected historical controls who had surgery alone (p = 0.12). The survival of all patients receiving BCG alone has not reached the 75 percentile yet, and the difference from controls is currently estimated at the 18% level. The combination of 5-FU plus BCG (studied in 32 patients) may be superior to BCG alone at this time, in that it appears to more effectively protect against tumor recurrence (75 percentile not yet reached compared to control, (p = 0.08). The survival of patients on 5-FU plus BCG also appears to be improved (p = 0.09). No patients have expired compared to a 75 percentile survival of 16.6 months in the control. Serial determination of plasma CEA was crucial in the clinical follow-up of these patients. Frequent CEA detetminations have led to early detection of clinical relapse. In the elevation of CEA suggests tumor recurrence with a high degree of probability in patients with past history of cancer of the large bowel.