Urinary tract infection in a human male patient with Staphylococcus pseudintermedius transmission from the family dog.

Staphylococcus pseudintermedius is increasingly recognized as a human pathogen. We report the first case of an urinary tract infection in a male patient with this organism.

Persistent infection with Staphylococcus pseudintermedius in an adult oncology patient with transmission from a family dog.

Staphylococcus pseudintermedius is a well known commensal organism of dogs but also a canine opportunistic pathogen. Reports of this organism being recovered from specimens from humans might suggest an increase prevalence in human infections and/or improved diagnostic leading to more accurate identification. Here we report a case of persistent S. pseudintermedius infection in an adult female oncology patient including colonization of the tip of an indwelling catheter. Diligence by laboratories in correctly isolating and identifying this pathogen (including susceptibility testing) is essential for optimal patient care.

The use of superficial cervical plexus block in oral and maxillofacial surgical practice as an alternative to general anesthesia in selective cases.

AIM: (1) To assess the feasibility, safety, and effectiveness of superficial cervical plexus (SCP) block in oral and maxillofacial surgical (OMFS) practice as an alternative to general anesthesia in selective cases. (2) To assess any associated complication specifically related to the procedure. SUBJECTS AND METHODS: The total number of patients was 10, out of which 6 were male and 4 were female patients. Six patients had incision and drainage of perimandibular space infections, two patients had Level Ib cervical lymph node biopsies, one patient had enucleation of cyst in the body of mandible, one patient had open reduction and internal fixation isolated angle fracture. Informed written consent was obtained from the patients after they had the procedure explained to them. Exclusion criteria included patient's refusal to undergo the procedure under regional anesthesia, allergy to local anesthetic, excessively anxious, and apprehensive patients, significant upper airway compromise warranting an endotracheal intubation to secure airway. All patients had the procedure done by the same operating surgeon. All patients had their surgical procedures under regional anesthesia (SCP block with supplemental nerve blocks) performed by the same surgeon with satisfactory anesthesia and analgesia without any complication. RESULTS: SCP block with concomitant mandibular nerve and long buccal nerve block has a high success rate, low complication rate, and high patient acceptability as shown in the study. CONCLUSION: The notable anesthetic effect and adequate working time, summed with the low risk of accidents and complications, make this technique a good alternative for sensitive blockage of part of the cranial and cervical regions and have positive outcomes in selective OMFS cases.

Bilateral synchronous low-grade adenosquamous carcinoma of the breast: A Case report with review of the current literature.

INTRODUCTION: Low-grade adenosquamous carcinoma (LGASC) is a rare, unique variant of metaplastic breast carcinoma, characterized by clinical indolence and low-grade cytomorphology. Being clinically asymptomatic with indefinite imaging characteristics, diagnosis is solely dependent on histopathology. PRESENTATION OF CASE: A 68-year-old woman presented to the Breast Health Center with mammogram-detected left-sided retroareolar calcifications. She had a three-year history of non-progressive bilateral nipple inversion, and was otherwise asymptomatic. Left breast biopsy revealed atypical metaplastic squamous epithelial cells. Subsequently a wire-guided lumpectomy diagnosed a syringomatous adenoma of the nipple. A surveillance MRI identified a contralateral breast lesion, which on core biopsy showed an atypical adenosquamous lesion. Bilateral central mastectomies with bilateral sentinel node biopsies were undertaken. Histopathological review of both breast specimens confirmed the unique features of adenosquamous carcinoma identified by an infiltrative pattern of small rounded compressed angulated glands with squamous differentiation and low-grade cytomorphology. The tumors were triple negative [ER, PR, HER2]. The sentinel lymph nodes were negative. CONCLUSION: Bilateral synchronous LGASC of the breasts is exceedingly uncommon and remains a diagnostic and therapeutic challenge. Despite being triple negative, due to its indolent behavior, recognition of this unusual primary breast malignancy is important as it has a more favorable prognosis. Yet, due to its rarity, there are no guidelines for best practice management regarding the role of adjuvant therapy.

Unexpected intra-operative diagnosis of a large cystic phaeochromocytoma and secondary nifedipine pharmacobezoar.

Cystic phaeochromocytoma is a rare neuro-endocrine tumour that is frequently asymptomatic and often diagnosed incidentally on imaging or intra-operatively. A pharmacobezoar is a rare complication of extended-release drug delivery systems. We present a case of a 70-year-old woman diagnosed intra-operatively with cystic phaeochromocytoma and antihypertensive pharmacobezoar.

Uncommon mucosal metastases to the stomach.

BACKGROUND: Metastases to the stomach from an extra-gastric neoplasm are an unusual event, identified in less than 2% of cancer patients at autopsy. The stomach may be involved by hematogenous spread from a distant primary (most commonly breast, melanoma or lung), or by contiguous spread from an adjacent malignancy, such as the pancreas, esophagus and gallbladder. These latter sites may also involve the stomach via lymphatic or haematogenous spread. We present three cases of secondary gastric malignancy. METHODS/RESULTS: The first is a 19-year-old male who received a diagnosis of testicular choriocarcinoma in September 2004. Metastatic malignancy was demonstrated in the stomach after partial gastrectomy was performed to control gastric hemorrhage. The second is a 75-year-old male, generally well, who was diagnosed with adenocarcinoma of the lung in September 2005. Poorly differentiated adenocarcinoma of the lung was demonstrated in a subsequent biopsy of "gastric polyps". The third is an 85-year-old man with no known history of malignancy who presented for evaluation of iron deficiency anemia by endoscopy in February 2006. Biopsies of the colonic and gastric mucosa demonstrated moderately differentiated invasive colonic adenocarcinoma with metastatic deposits in the stomach. CONCLUSION: While the accurate recognition of these lesions at endoscopy is fraught with difficulty, pathological awareness of such uncommon metastases in the gastric mucosa is essential for accurate diagnosis and optimal patient management.

Use of ultrasound biomicroscopy to image human ovaries in vitro.

OBJECTIVES: To test the hypothesis that ultrasound biomicroscopy is an effective tool for imaging human ovaries in vitro. METHODS: This was a prospective, observational study of 11 women (mean age, 48.9 +/- 2.3 years; range, 40-65 years) undergoing unilateral or bilateral oophorectomy. Ovaries were obtained in the operating room and imaged in a cooled saline bath using conventional two-dimensional (2D) ultrasound. Follicles identified using conventional 2D ultrasound were then imaged in a cooled saline bath using ultrasound biomicroscopy. Ovaries were then placed in 10% neutral-buffered formaldehyde and transported to the Pathology Department for histological evaluation. Digital images of individually identified ovarian follicles using conventional ultrasound, ultrasound biomicroscopy and histology were obtained (n = 22). Thicknesses of the follicle wall, granulosa layer and theca interna layer were measured using standardized techniques. RESULTS: The imaging sensitivity, defined as the smallest follicle visualized, was greater using ultrasound biomicroscopy (0.33 +/- 0.07 mm) than it was using conventional ultrasound (1.5 +/- 0.21 mm; P < 0.0001). The mean follicle wall thickness was greater using conventional ultrasound (0.675 +/- 0.039 mm) compared with ultrasound biomicroscopy (0.254 +/- 0.017 mm), which in turn, was greater than that measured by histology (0.160 +/- 0.009 mm) (P < 0.0001). The mean granulosa and theca layer thickness measurements, respectively, were greater using ultrasound biomicroscopy (0.067 +/- 0.004 mm; 0.186 +/- 0.014 mm) compared with histology (0.034 +/- 0.002 mm; 0.126 +/- 0.008 mm) (P < or = 0.001). Protrusions from the follicle wall into the antrum, believed to represent cumulus-oocyte complexes, were visualized in five of 22 follicles using ultrasound biomicroscopy. CONCLUSIONS: The ultrasound biomicroscope was an effective tool to image human ovaries in vitro. Ultrasound biomicroscopy provided greater sensitivity and resolution for imaging ovarian follicles compared with conventional 2D ultrasonographic techniques.

Pathological validity of esophageal endoscopy. How real is what we see? Myth or reality?

The purpose of this study was to characterize the spectrum of esophageal pathology at a provincial tertiary care hospital and to evaluate these findings with their respective endoscopic diagnoses. The pathology slides of 183 esophageal biopsies for the year 2000 were reviewed and classified as esophagitis, intestinal metaplasia, low or high grade dysplasia, adenocarcinoma, squamous cell carcinoma or normal. One hundred and fifteen cases (63%) had complete concordant results with respective endoscopic reports. Sixty-eight cases (37%) had discordant results with inaccurate recognition of Barrett's esophagus in 9% and of esophagitis with a false positive in 16% and false negative in 7%. Although esophagoscopy remains a primary investigative tool in gastroesophageal diseases, evaluation of erythema, inflammation and esophagitis can be misleading. Pathologically confirmed esophagitis can occur in a 'normal' esophagus. Accurate endoscopic recognition of short-segment Barrett's remains a diagnostic challenge.

Clonal B cell populations in a minority of patients with Hashimoto's thyroiditis.

BACKGROUND: Hashimoto's thyroiditis (HT) is a risk factor for thyroid lymphoma, and clonal B cell populations in HT support this link. The literature on B cell clonality in HT is controversial. AIMS: To identify clonal B cell populations in HT and to assess their usefulness in differentiating HT from mucosa associated lymphoid tissue (MALT) lymphoma and predicting future development of lymphoma. METHODS: DNA from formalin fixed, paraffin wax embedded blocks of thyroid specimens from 10 patients with HT and two thyroid MALT lymphomas was analysed for B cell clonality by seminested polymerase chain reaction (PCR) using FRIII/LJH and FRIII/VLJH primers to amplify the IgH gene VDJ region. In one case, PCR products were sequenced. Immunohistochemistry was performed by labelled streptavidin-biotin technique using antibodies to: CD45, CD45RO, CD3, CD20, and cytokeratin. RESULTS: The histopathological and clinical findings were characteristic of HT. Clonal bands were seen in three and a polyclonal smear pattern was seen in seven cases. The clonal bands in HT were associated with a background smear, and could not be reproduced from other blocks from the same case or from deeper sections of the same block. The clonal bands in thyroid lymphomas were not associated with a background smear and were reproducible. None of the patients with clonal B cells has developed malignant lymphoma during a follow up of 10-13 years. CONCLUSIONS: B cell clonal bands in HT have different features from those in lymphoma (non-pure and non-reproducible) and do not predict future development of lymphoma.

Squamous cell carcinoma of the prostate. A report of 6 cases.

Squamous cell carcinoma of the prostate is uncommon. In an attempt to assess the incidence of squamous cell carcinoma of the prostate, we searched the records of the Saskatchewan Cancer Agency over the past 30 years. Using strict diagnostic criteria a total of 6 cases of pure squamous cell carcinoma among 13,497 cases of prostatic carcinoma were identified. The ages of these patients ranged from 42 to 85 years. The survival rates of these cases ranged from 1 to 13 months.

Male versus female breast cancers. A population-based comparative immunohistochemical analysis.

CONTEXT: The rate of male breast cancer is a small fraction of that observed in females, thus severely limiting our understanding of the pathogenesis of this condition. It remains unclear whether the biological behavior and tumor progression associated with male breast cancer parallel that of the female form. OBJECTIVES: To evaluate the immunohistochemical profile of male breast carcinomas and to compare this profile with that of stage-matched female breast cancers. DESIGN: Seventy-five cases of primary male breast cancer were identified using the records of the Saskatchewan Cancer Foundation over a period of 26 years (1970-1996). Fifty-nine of these cases had formalin-fixed, paraffin-embedded tissue blocks available for the purposes of this study. All cases were reviewed and a standardized modified Bloom-Richardson grading criterion was applied. Estrogen receptor status, progesterone receptor status, c-Erb-B2 expression, p53 expression, and Bcl-2 expression were evaluated by immunohistochemistry. Results from 240 consecutive cases of stage-matched female breast cancers analyzed in the same laboratory were used as a standard set for comparison. RESULTS: Male breast cancers tended to be high grade (85% grade 3) in comparison with the female breast cancers (50% grade 3). In descriptive analysis across all stages of disease, male carcinomas were more frequently estrogen receptor positive (81% vs 69%) than their female counterparts. Despite their high grade, they were less likely to overexpress p53 (9% vs 28%) and Erb-B2 (5% vs 17%) than the female counterparts. There was no significant difference in either progesterone receptor (63% vs 56%) or Bcl-2 (79% vs 76%) overexpression. Stratified analysis by stage-matched controls showed no statistically significant differences among the men and women with stage I disease. However, in stage II-matched samples, statistically significant differences were observed between the 2 groups. The male cancers were more likely to overexpress estrogen receptor (81.6% vs 64.4%, P = .04), progesterone receptor (71.1% vs 47.5%, P = .01), and Bcl-2 (78.9% vs 69.4%, P = .20). They also showed statistically significant lower expression of p53 (7.9% vs 36.3%, P = .001) and Erb-B2 (5.3% vs 23.8% P = .01). CONCLUSION: Male breast cancers display distinct immunophenotypic differences from those occurring in women, implying a different pathogenesis in the evolution and progression of this disease. Such differences may play key roles in therapeutic management, warranting different treatment strategies in comparison to female breast cancers.

Goblet cell carcinoids of the appendix: immunophenotype and ultrastructural study.

BACKGROUND: Goblet cell carcinoids of the appendix are rare neoplasms with uncertain biological behavior. OBJECTIVE: The aims of our study were to evaluate the immunophenotype of this neoplasm with cell cycle/cell proliferation markers and to understand their histogenesis with ultrastructural analysis using conventional carcinoids as a frame of reference. METHODS: Clinical data and archival pathologic material of all goblet cell carcinoids of the appendix recorded by the Saskatchewan Cancer Registry between 1970 and 1998 were reviewed and evaluated by light microscopy, histochemistry, immunohistochemistry, and electron microscopy. RESULTS: Seven cases of goblet cell carcinoids were identified among 110 cases of conventional carcinoids of the appendix. Histopathology revealed widespread infiltration of the periappendiceal fat in all cases, with extensive perineural invasion. The cells stained strongly positive for mucicarmine, periodic acid-Schiff, periodic acid-Schiff diastase, Alcian blue, cytokeratin, and carcinoembryonic antigen. Most cases were positive for synaptophysin. Increased expression of cell proliferation markers and cell cycle markers was observed. Expression of p53 was strong in one case. Electron microscopy demonstrated the presence of mucinous vacuoles of varying sizes and occasional membrane-bound neuroendocrine granules. CONCLUSIONS: Goblet cell carcinoids of the appendix arise from a pluripotent cell with divergent neuroendocrine and mucinous differentiation. These neoplasms are widely invasive; they demonstrate a high cellular proliferation rate and dysregulation of the cell cycle with up-regulation of cyclin D1 and p21, and down-regulation of p16. Complete removal of the tumor is recommended because of the unpredictable biological behavior of this tumor, which includes delayed local recurrences and lung metastases.

Gallbladder carcinomas: an immunoprognostic evaluation of P53, Bcl-2, CEA and alpha-fetoprotein.

The p53 gene is the most frequently mutated gene in many human cancers, including those of the colon, breast, lung, esophagus, liver and brain. Such genetically mutated tumours are generally associated with progression of the disease and poor clinical outcome. One hundred cases of documented gallbladder carcinomas were reviewed. Twenty-eight cases were randomly selected to evaluate the expression of P53, Bcl-2, carcinoembryonic antigen (CEA) and alpha-fetoprotein, in both the in situ (19 cases) and invasive components (28 cases) of the tumour by the avidin-biotin complex method of immunohistochemistry. These results were correlated with the mean survival intervals in an effort to clarify the progression of the disease and evaluate their role as prognostic markers. Staining to alpha-fetoprotein and Bcl-2 remained consistently negative to weak insignificant staining in both the in situ and invasive components of the tumour in all cases. P53 staining of the invasive part of the tumour was seen in 24 (86%) of the cases and in 17 (89%) of the in situ component. The in situ staining patterns of P53 were not statistically significant in relation to the mean survival. However, in the invasive component, moderate to strong staining tumours, as seen in 15 (54%) cases, were associated with a mean survival of 8.8 months. A similar trend was also observed with staining patterns to CEA. Eighty-nine per cent of the invasive and 84% of the in situ components of the tumour stained positive to CEA. Moderate to strong staining of both the in situ and the invasive components of the tumours was associated with a mean survival of 10.6 months in 76% of cases. This study shows that altered expressions of P53 and CEA are detectable by immunohistochemistry in gallbladder carcinomas. Tumours with increased expression of P53 and CEA of a strong to moderate staining were associated with poor clinical outcomes as evidenced by their mean survival. A stepwise progression of altered CEA and P53 expression may reflect ongoing progression of the disease from the in situ to the invasive phase. However, such trends need to be evaluated in larger numbers and are thus not considered to be true independent prognostic markers.

p53, ErbB2, and TAG-72 expression in the spectrum of ductal carcinoma in situ of the breast classified by the Van Nuys system.

CONTEXT: The Van Nuys (VN) classification system for ductal carcinoma in situ (DCIS) of the breast is a simplified morphology-based system that uses the presence of nuclear pleomorphism and comedo-type necrosis to stratify DCIS lesions into 3 prognostic groups. OBJECTIVE: To determine if there is an underlying biological basis that correlates with the morphologic aspects of the VN classification system. DESIGN: We evaluated the expression of markers implicated in the development of breast cancer (p53, ErbB2, and TAG-72) in DCIS classified with the VN system. Forty-five cases of pure DCIS were classified as 8 cases of VN1, 7 cases of VN2, and 30 cases of VN3. p53, ErbB2, and TAG-72 antigen expression was measured by immunohistologic means in each of the cases. RESULTS: Nuclear accumulation of p53 was only observed in VN3 (30%). ErbB2 overexpression was found only in VN2 (14%) and VN3 (43%). TAG-72 expression was observed in all categories of lesions but was more frequent in VN2 (71%) and VN3 (70%) compared with VN1 (25%). It appears that overexpression of ErbB2 and p53 are features associated with the high-grade lesions. CONCLUSION: The simplified VN classification system for DCIS has a clear underlying biological basis as evidenced by differential expression of tumor-associated antigens in each of the 3 morphologic categories. These differences may contribute to the differential clinical behavior of the separate groups.

Distinct B-cell clonal bands in Helicobacter pylori gastritis with lymphoid hyperplasia.

Helicobacter pylori (Hp)-associated gastritis is a risk factor for gastric mucosa-associated lymphoid tissue (MALT) lymphoma. Clonal B-cell populations are present in both reactive and neoplastic MALT tissue, thus limiting their usefulness in the evaluation of gastric lymphoid infiltrates in endoscopic biopsy specimens. The aim of this study was to identify the presence of clonal B-cell populations in Hp-gastritis with MALT and to assess their usefulness in distinguishing reactive from malignant infiltrates. Routinely fixed paraffin-embedded blocks from 20 patients with Hp-gastritis with lymphoid hyperplasia were analysed for B-cell clonality by a semi-nested polymerase chain reaction (PCR) using FRIII/LJH and FRIII/VLJH primers for amplification of the VDJ region of the immunoglobulin heavy chain gene. The histopathological findings were evaluated according to a previously published scoring system. Immunohistochemistry was performed by the labelled streptavidin-biotin technique using the following primary antibodies: CD45, CD45RO, CD3, CD20, and cytokeratin. The histopathological findings were diagnostic of Hp-chronic active gastritis (grade 2, n=17; grade 3, n=3). Scattered intraepithelial B-cells were present in all cases and non-destructive lymphoepithelial lesions in one grade 3 case. Amplifiable DNA was obtained from all samples. Clonal bands were observed in ten (7/17 grade 2 and 3/3 grade 3 lesions) and polyclonal smears in ten cases (all grade 2). The clonal bands were often (n=6) associated with a background polyclonal smear and were not reproducible from deeper sections (n=10) or another paraffin block (n=1), while the clonal bands in control low-grade MALT lymphomas were not associated with a background smear and were reproducible from deeper sections. None of the patients has developed lymphoma to date (follow-up 21-44 months). In conclusion, B-cell clonal bands are common in H. pylori-gastritis with lymphoid hyperplasia. The irreproducibility of these bands is a useful feature in favouring a reactive process.

Skeletal metastases in colorectal carcinomas: a Saskatchewan profile.

PURPOSE: Colorectal cancer is the third leading cause of cancer-related deaths in the world. Death is usually attributed to progress of the disease with recurrence and metastases. Skeletal metastases in primary colorectal cancer is an uncommon event. When such an event occurs, it is usually a late manifestation of the disease. In our study this phenomenon is analyzed in a population-based database. METHODS: This report is a 25-year retrospective review that covers patients with skeletal metastases secondary to colorectal carcinomas registered at The Saskatchewan Cancer Foundation from 1970 to 1995. The latter is the sole registration agency of all cancers in the one million population base of the province of Saskatchewan. RESULTS: A total of 5,352 cases of primary colorectal carcinomas were seen between 1970 and 1995. Of these, 355 had skeletal metastases. The incidence of osseous metastases in our institution is 6.6 percent. Among the latter, 60 cases (16.9 percent) had skeletal metastases only, whereas 295 cases (83.1 percent) had skeletal metastases in combination with lung, liver or brain metastases. This is in keeping with the fact that solitary skeletal metastases from a primary colonic carcinoma is a rare event, with an incidence of 1.1 percent in our institution. The disease-free interval from the time of diagnosis of the cancer to the onset of skeletal metastases ranged from 10 days to 5,309 days. Thirty-eight percent of the cases with skeletal metastases only were alive at the end of five years in comparison with 16 percent of the cases with skeletal and other metastases. However, there was no significant difference in the ten-year survival curves from the onset of osseous metastases in the two groups. The majority were diagnosed by a bone scan or plain radiography or both. Most cases in our institution received a multimodal treatment consisting of radiotherapy in conjunction with palliative surgery or chemotherapy or both. Radiotherapy was, however, the most effective therapy for painful skeletal metastases. CONCLUSION: Skeletal metastasis is a rare event in primary colorectal carcinomas. Among these cases there is an emerging trend of a different clinical-biological behavior pattern between patients who develop solitary skeletal metastases vs. patients with skeletal and other organ metastases.

The 'true' splenic wanderer.

Wandering spleen is an unusual entity and remains an elusive clinical diagnosis. Among the modern imaging modalities including computed tomography, magnetic resonance imaging, nuclear scans and ultrasonography, the latter appears to be the least invasive and the most effective in reaching a definitive diagnosis. A patient with 'true' wandering spleen who presented with chronic, intermittent abdominal pain, weight loss and a right lower quadrant mass that was interpreted as a pelvic lymphoma or a primary pelvic malignancy on computed abdominal tomography (CAT) scan is presented. Abdominal ultrasonography conducted a few weeks before the CAT scan showed a normal splenic shadow in the left upper abdomen.

Asplenia as a cause of sudden unexpected death in childhood.

Sudden unexpected death in childhood is rare. The commonest causes of such deaths are a result of fulminating infections of the respiratory or nervous systems. Other causes include unsuspected congenital abnormalities of the heart, acute metabolic disorders, and rarities such as internal hemorrhages and pulmonary thrombosis. Recognition of children with congenital asplenia who are otherwise normal but have an increased susceptibility to overwhelming sepsis is extremely difficult. We reviewed 1763 autopsy files from our institution over 5 years (1990-1995), of which 293 were classified as pediatric cases. The vast majority of the cases were stillbirths and deaths within the first year of life as a result of complex congenital anomalies. Four cases of asplenia were identified in our entire series, 3 of which were of the congenital syndromal variety and 1 of which was a case of isolated sporadic congenital asplenia. All 4 cases of asplenia were analyzed in detail with respect to autopsy findings and cause of death. Severe complex cardiac malformations were present in the congenital syndromal asplenia patients; these other malformations contributed significantly to their death. In this report, we discuss in detail the autopsy findings in a previously healthy 4-year-old girl who presented with a brief 8-hour history of being unwell and died within 4 hours of admission into the hospital. She had sporadic, isolated congenital asplenia complicated by high-grade type 6B pneumococcemia and acute bilateral adrenal hemorrhage (Waterhouse-Friderichsen syndrome). Previously healthy children who clinically deteriorate very rapidly should have a blood smear done as part of their clinical workup. The detection of Howell-Jolly bodies on a peripheral blood smear can be an indicator of asplenia, and this diagnosis can be confirmed by medical imaging of the abdomen. Such steps may aid in the aggressive management of isolated congenital asplenia and thereby avert untimely death.