Hysteroscopic biopsy compared with endometrial curettage to assess the preoperative rate of atypical hyperplasia underestimating endometrial carcinoma.

PURPOSE: To evaluate the rate of atypical hyperplasia (AH) underestimating endometrial cancer (EC) comparing endometrial biopsy (EB) accomplished by hysteroscopic biopsy with dilatation and curettage (D&C). Second, to compare the two techniques to foresee EC grading. METHODS: This trial was based on the findings of two Gynecological Departments within the same Public Utility, sharing pathological service and database but routinely performing EB under hysteroscopic visualization (group A) or hysteroscopy followed by D&C (group B). We retrieved the clinical data of patients showing EC on hysterectomy throughout a 10-year period. The accuracy of hysteroscopic-view diagnosis and EB pathology were compared, having the pathologic findings of hysterectomy as reference. RESULTS: A total of 161 patients met the inclusion criteria. Among these, 109 and 52 were included in groups A and B, respectively. In group A, 32.1% of patients underwent EB in an out-patient setting. To foresee EC, hysteroscopic view showed a sensitivity of 82.5% and 70.2% in groups A and B, respectively (P = 0.019). An underestimation of EC diagnosed as AH on EB was found in 20 patients (12.4%). Among these, 18 (16.5%) and 2 (3.8%) were included in groups A and B, respectively (P = 0.022). In group A, a fault diagnosis of AH resulted higher when EB was performed as out-patient setting (P = 0.006). EB allowed the grading of EC in 73.3% and 90.3% of patients in groups A and B, respectively. The agreement was 73.7% and 85.1%, leading to moderate (κ = 0.56) and good (κ = 0.77) "κ" coefficient of concordance for groups A and B, respectively. CONCLUSIONS: EB performed by D&C lowers the rate of AH underestimating concurrent EC and improves the grading agreement when compared with hysteroscopic sampling.

Appendiceal diverticulitis, a rare relevant pathology: Presentation of a case report and review of the literature.

INTRODUCTION: Appendiceal diverticulitis is a rare pathology that mimics acute appendicitis. Appendiceal diverticula are classified into congenital and acquired with difference in incidence and pathogenesis. Appendiceal diverticulitis is often overlooked because of mildness of symptomatology with increasing risk of complications, such as perforation. Appendiceal diverticula are often associated to higher risk of neoplasm especially carcinoid tumors and mucinous adenomas. PRESENTATION OF CASE: A 40-year-old caucasic male presented into Emergency Room with right lower quadrant pain associated with vomit, abdominal tenderness, fever and moderate leukocytosis (11.93×10; neutrophils 78.5%). Acute appendicitis was suspected and a surgical approach was chosen with a McBurney access. The removed specimen (Figs. 1 and 2) was 11cm long with multiple hyperaemic and oedematous diverticular protrusions. The postoperative course was regular. Discharging was on 4th postoperative day in optimal clinical conditions. The histological examination (Fig. 3) showed acute inflammation of appendiceal pseudodiverticula with acute peridiverticulitis and abscess. DISCUSSION: Currently, appendiceal diverticulitis is often overlooked with high risk of complications, above all perforation. Attention should be kept during the surgical procedure and the patholological examination in order to identify any associated neoplasm. CONCLUSION: Appendiceal diverticulitis should be considered in adult male patients with right lower quadrant pain or tenderness. Accurate appendectomy should be performed in order to permit an appropriate pathological examination and possible associate neoplasm should always be searched through. Prophylactic appendectomy should be performed in case of incidental finding of appendiceal diverticula in asymptomatic patients in order to avoid the high perforation risk.

Hemangioblastoma-like clear cell stromal tumor of the lung.

The authors report 2 cases of an apparently unpublished stromal tumor of the lung characterized by a predominantly endobronchial growth pattern and benign-appearing clear cells. Both tumors were discovered incidentally in adult patients during routine workups for other medical reasons and treated with lobectomy. On gross inspection there was no evidence of infiltration of the adjacent lung tissue. Microscopically, both lesions featured monotonous oval-shaped to spindle-shaped cells growing in a vaguely nested pattern. The cytoplasm was slightly vacuolated or granular. In 1 case there was a variable admixture with mature fat. Immunohistochemistry was negative for markers of epithelial and stromal differentiation except for vimentin. A focal reaction for CD34 was seen in 1 case. No mutation of coding sequence of VHL gene was seen in one case. Medical follow-up at 1 year was negative for tumor recurrence or metastases. The broad differential diagnosis within the spectrum of stromal lung tumor is discussed. Owing to distinctive microscopic features such as the nesting of clear cells within a vascularized background, both tumors appeared similar to hemangioblastoma, although the expected immunohistochemical profile of the latter was not fully expressed. Because of pattern of growth seen in both lesions we believe that the appellation of endobronchial, hemangioblastoma-like clear cell stromal tumor may be provisionally designed.

Uterine tumor resembling ovarian sex cord tumors treated by resectoscopic surgery.

Uterine tumors resembling ovarian sex cord tumors (UTROSCTs) are rare neoplasms of uncertain malignancy, affecting either pre or menopausal women. Only 48 cases of UTROSCTs have been reported and in most patients the diagnosis was made incidentally, after a hysterectomy as a result of the assumption of a leiomyoma. Although no death from progressive disease was reported, locoregional spread or abdominal relapse was detected in some patients. Up until now, a treatment sparing the uterus was reported in only 2 patients with UTROSCTs. Both patients conceived after surgery and were free from recurrent disease after a mean follow-up of 16.5 months. We report a third case of a young patient affected by pure UTROSCTs and treated conservatively. A 29-year-old woman underwent resectoscopic hysteroscopy because of the assumption of a grade-1 submucous myoma measuring about 5 cm. To accomplish the removal of the endometrial mass, a 2-step hysteroscopic resection was required. Histology showed epithelioid cells arranged in nests, cords, tubules, and trabeculae infiltrating the myometrium; no sarcoma cell differentiation was detected. Immunohistochemistry resulted in positivity to CD99, inhibin, calretinin, cytokeratin, and estrogen receptor, whereas a negative staining to epithelial membrane antigen, actin, desmin, and human melanoma black 45 was obtained. Based on histologic pattern and immunohistochemical phenotype, a diagnosis of pure UTROSCTs was made; the staging of disease revealed neither locoregional spread nor distant metastases. Two months after surgery, reassessment by hysteroscopy and endometrial biopsy revealed no residual endometrial disease. The patient was free from disease 13 months after surgery. Because of the uncertain malignant potential of UTROSCTs and based on the poor data available from current literature, a fertility-sparing surgery in young patients appears safe. However, a close long-term follow-up is required and a quick completion of a patient's childbearing desire seems advisable.

Angiosarcoma of the uterus: report of 2 new cases with deviant clinicopathologic features and review of the literature.

A few cases of uterine angiosarcoma have been detailed in the literature: 2 new cases are herein described featuring some unusual clinical or phenotypic differences compared with previously published cases, such as occurrence in premenopausal age or a poorly differentiated histology. The patients were 35 and 81 years old, and both presented with extrauterine spread and evidence of distant metastases. Grossly, they were fleshy, hemorrhagic, and necrotic. Microscopically, they were made up of poorly differentiated, epithelioid, or spindle cells. In one case, the neoplastic growth deceitfully recalled a poorly differentiated leiomyosarcoma showing focal rudimentary endothelial differentiation. The other index case was characterized by a more pronounced vascular pattern, the neoplasm was composed of spindle cells arranged in loose channels. A diffuse immunopositivity for CD31, CD34, and factor VIII-related antigen was detected. Tumor cells were negative for other tested antigens including keratins, desmin, actins, and H-caldesmon. One patient died shortly during the follow-up, whereas the other is alive with evidence of disseminated disease. Occurrence in childbearing age or a deviant histologic pattern, as documented in this report, may be added to the clinicopathologic spectrum of uterine angiosarcoma.

Hysteroscopic view in atypical endometrial hyperplasias: A correlation with pathologic findings on hysterectomy specimens.

STUDY OBJECTIVE: To evaluate whether hysteroscopic imaging can contribute to decrease the rate of undetected endometrial carcinomas concurrent with atypical hyperplasia diagnosed by endometrial biopsy. DESIGN: Retrospective study. DESIGN CLASSIFICATION: Canadian Task Force Classification II-3. SETTING: Public hospital. PATIENTS: Hysteroscopic reports of 25 menopausal patients undergoing endometrial biopsy yielding a diagnosis of atypical hyperplasia were reviewed. On the basis of this diagnosis, all patients were treated by hysterectomy, and the pathologic findings on the uterine specimen were correlated with the diagnoses obtained by hysteroscopic view. INTERVENTIONS: Hysteroscopy was video-assisted and carried out with normal saline solution used as liquid distension medium; a 5-mm sheathed hysteroscope, with a working channel, was used for each examination. After hysteroscopic inspection, an endometrial sampling targeted under vision was performed by mechanical or electrosurgical instrumentation. When extensive features of hyperplastic or neoplastic growth were observed, we combined a blind sampling procedure with Vabra-curettage. We calculated the sensitivity, specificity, and negative and positive predictive values of hysteroscopic inspection to foresee the diagnosis of endometrial cancer incidentally detected on hysterectomy specimen. MEASUREMENTS AND MAIN RESULTS: On the basis of histopathologic study of uterine specimens, non atypical hyperplasias were detected in 3 patients, the diagnosis of complex atypical hyperplasia was confirmed in 11 patients, whereas a concurrent infiltrating endometrial adenocarcinoma was detected in 11 patients (44.0%). In the 14 patients with diagnosis of endometrial hyperplasia, no feature suggesting endometrial malignancy was reported by hysteroscopic inspection. In the 11 cases showing infiltrating carcinomas, hysteroscopic view was consistent with endometrial malignancy in 9 patients and with endometrial hyperplasia in 2 patients. An intramucous endometrial carcinoma without evidence of myometrial invasion was found on hysterectomy specimens of these two latter patients. From these figures, sensitivity, specificity, and negative and positive predictive values of hysteroscopy to foresee a diagnosis of infiltrating carcinoma were 84.6%, 100%, 87.5%, and 100%, respectively. CONCLUSIONS: Hysteroscopic view is a sensitive and specific method to identify among patients with a diagnosis of atypical hyperplasia on endometrial biopsy those with a coexisting infiltrating carcinoma.

Solitary fibrous tumor of the mammary gland: a potential pitfall in breast pathology.

We report three cases of solitary fibrous tumor of the breast. The patients were adult to elderly women and complained of a slowly but relentless growing lump. The tumors were fairly circumscribed and cured by means of lumpectomy or, in one case, simple mastectomy. Histologically, they featured the customary "patternless pattern" of short spindle cells haphazardly arranged in fascicles within a collagenized or myxoid ground substance. In two cases, a prominent hemangiopericytic arrangement of tumor cells around a rich vascular framework could be noticed. Cellular areas were often present and showed nuclear overlapping, clumping of chromatin, and a brisk mitotic activity. No atypical mitosis was recognized. Tumor cells were immunoreactive for CD34, bcl2, and vimentin only. On follow-up there was no evidence of either local recurrence or distant metastases. Solitary fibrous tumors of the breast may represent a significant diagnostic problem because of the close mimicry to numerous benign and malignant mammary lesions composed of spindle cells; diagnostic clues may be further obscured in cellular and actively proliferating tumors. A brief overview of mammary solitary fibrous tumor taxonomy along with the principal differential diagnoses within the breast is presented.

Differential cytokine pattern in the spleens and livers of BALB/c mice infected with Penicillium marneffei: protective role of gamma interferon.

Penicillium marneffei is an intracellular opportunistic fungus causing invasive mycosis in AIDS patients. T cells and macrophages are important for protection in vivo. However, the role of T-cell cytokines in the immune response against P. marneffei is still unknown. We studied by semiquantitative reverse transcription-PCR and biological assays the patterns of expression of Th1 and Th2 cytokines in the organs of wild-type (wt) and gamma interferon (IFN-gamma) knockout (GKO) mice infected intravenously with P. marneffei conidia. At 3 x 10(5) conidia/mouse, a self-limiting infection developed in wt BALB/c mice, whereas all GKO mice died at day 18 postinoculation. Splenic and hepatic granulomas were present in wt mice, whereas disorganized masses of macrophages and yeast cells were detected in GKO mice. The infection resolved faster in the spleens than in the livers of wt mice and was associated with the local expression of type 1 cytokines (high levels of interleukin-12 [IL-12] and IFN-gamma) but not type 2 cytokines (low levels of IL-4 and IL-10). Conversely, both type 1 and type 2 cytokines were detected in the livers of wt animals. Disregulation of the cytokine profile was seen in the spleens but not in the livers of GKO mice. The inducible nitric oxide synthase mRNA level was low and the TNF-alpha level was high in both spleens and livers of GKO mice compared to wt mice. These data suggest that the polarization of a protective type 1 immune response against P. marneffei is regulated at the level of individual organs and that the absence of IFN-gamma is crucial for the activation of fungicidal macrophages and the development of granulomas.