Malignant tumor with chest wall pain mimicking Tietze's syndrome.

Chest pain is commonly caused by musculoskeletal chest wall disorders. Tietze's syndrome is a relatively rare cause of chest wall pain characterised by non-suppurative, painful swelling of the upper costal cartilages. The diagnosis should be based on these classic clinical features after excluding other potential causes of pain. A patient who was diagnosed with Tietze's syndrome but was found to have squamous cell carcinoma of the mediastinum with unknown primary site invading the sternum and anterior chest wall is presented for discussion.

Duodenal somatostatinoma of the ampulla of vater diagnosed by endoscopic fine needle aspiration biopsy: a case report.

BACKGROUND: Duodenal somatostatinoma is a rare neuroendocrine neoplasm. A better prognosis can be obtained if these tumors are resected at an early clinical stage. Endoscopic punch biopsy has been the method most commonly used for the preoperative diagnosis of neuroendocrine duodenal tumors. To the best of our knowledge, endoscopic fine needle aspiration biopsy (FNAB) of duodenal somatostatinoma has not been reported before. CASE: A 41-year-old, black female presented with upper gastrointestinal bleeding as well as elevated bilirubin, liver enzymes and glucose. Computed tomography, esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography (ERCP) detected a mass at the region of the ampulla of Vater partially obstructing the pancreatic duct. The initial punch biopsy yielded only intestinal mucosa. Subsequent endoscopic FNAB suggested the diagnosis of a neuroendocrine neoplasm, as confirmed by additional punch biopsies. Immunohistochemical and electron microscopic studies disclosed somatostatin production by the tumor, which was resected through a modified Whipple procedure. The patient recovered fully. CONCLUSION: This case demonstrates the usefulness of endoscopic FNAB in diagnosing submucosal gastrointestinal neuroendocrine tumors.

Acute respiratory distress syndrome and blastomycosis: presentation of nine cases and review of the literature.

Mississippi has the highest prevalence of blastomycosis in the country. In 20 years and 5 months there were 123 patients treated for blastomycosis at the University of Mississippi Medical Center. Among these, 107 patients had lung involvement and nine patients (8.4%) developed acute respiratory distress syndrome. Seven of the nine patients (78%) died of respiratory failure. In six patients, the lungs were the only organs involved. The three other patients had involvement of other organs as well. Average survival after the onset of acute respiratory distress syndrome was 6.9 days (range, 2 to 17 days). Acute respiratory distress syndrome can be triggered by pulmonary infections caused by bacterial diseases and other fungi. Massive proliferation of yeasts in the pulmonary parenchyma is the typical finding of patients with blastomycosis and acute respiratory distress syndrome. Underlying diseases that lead to immunodepression were present in only one patient and probable partial immunodepression was present in two other patients. Data from 19 other cases reported in the literature are discussed. Ann Diagn Pathol 5:1-9, 2001.

Cytohistologic correlation in patients with clinical symptoms of postmenopausal bleeding.

Today, the life expectancy for women is longer; therefore, many will likely experience the postmenopausal period (termination of fertility and menstrual bleeding). Uterine bleeding after this period is a sign of pathologic condition. The specific objective of this project was to evaluate the cytohistologic findings in women with postmenopausal bleeding (PMB) and to determine the presence of any significant pathologic lesions. Cytohistologic correlations from 66 patients attained in 1993 from the University of Mississippi Medical Center were evaluated. The population evaluated were divided into three groups: (control group 1) dysfunctional uterine bleeding (DUB), (control group 2) postmenopausal (PMP), and (test group 3) the group of women with postmenopausal bleeding. The DUB and PMP age-matched controls (n = 12, mean age 51 +/- 5 and 57 +/- 5 years) were randomly selected, and correlated with the actual group being tested (54 PMB, mean age 57 years). The distribution among the 54 PMB women evaluated were 69% (37/54) black, and 31% (17/54) white. The DUB and PMP control groups consisted of 50% (6/12) black and 50% (6/12) white, respectively. Histopathological confirmation (62/66--94%) revealed 47/66 as negative, 5/66 as endometrial hyperplasia and 10/66 as squamous cell carcinoma or adenocarcinoma. A significant lesion with endometrial pathology was found in 23% of the patients. These findings suggest that the majority of women in this study with clinical symptoms of postmenopausal bleeding were negative for malignancies. While these results lean more towards a normal cytologic evaluation, postmenopausal bleeding should not be taken lightly. Postmenopausal bleeding could represent signs of more serious lesion such as squamous cell carcinoma or endometrial adenocarcinoma if not detected and managed early.

Blastomycosis: organ involvement and etiologic diagnosis. A review of 123 patients from Mississippi.

Blastomycosis can only be diagnosed through the identification of the yeasts of Blastomyces dermatitidis in body fluids, tissues, or cultured material. The charts from 123 patients treated for blastomycosis at the University of Mississippi Medical Center from January 1980 through May 2000 were reviewed to determine the role of wet preparation, cytology, histology, and culture in diagnosing this fungal disease. Cytology uncovered the etiologic agent in 56.1% of all cases and in 71.8% of pulmonary cases. Cytology also was the first method to disclose the fungus in 57.7% of pulmonary cases. Sputum was the cytology specimen examined in 51% of the patients. In 69 patients with lung involvement, pulmonary cytology was positive in 97% of cases. Wet preparation was the second method to most commonly uncover the fungus in 37.4% of all cases. Histology was the third method with 32.5% of positive cases. Cultures were positive in 64.2% of all cases but they were the first to detect the fungus in only 3.2% of all patients. There was pulmonary involvement in 87% of patients, cutaneous involvement in 20%, osseous involvement in 15%, and central nervous involvement in 3%. In the medical literature the relative proportion of pulmonary versus disseminated disease clearly increased in series reported after 1959. Proportionally to the pattern of patients admitted to the University of Mississippi Medical Center, there is a clear predominance of black males among patients with blastomycosis followed by black females. White females constitute the sex/ethnic group least affected by this fungal disease.

Fine needle aspiration biopsy of the penis: transitional cell carcinoma of the urinary bladder with mucinous differentiation.

We report a case of transitional cell carcinoma of the urinary bladder metastatic to the penis. The diagnosis was established by fine needle aspiration biopsy (FNAB). Malignant cells showed mucinous differentiation. Ancillary studies carried out in the FNA material as well as in the primary bladder carcinoma suggested transitional cell carcinoma with mucinous differentiation. FNAB proved to be effective in diagnosing a secondary neoplasm to the penis. Mucoid differentiation of urothelial cells can be seen in FNAB specimens and might pose a problem in differential diagnosis.

Cytomorphology of tyrosine-rich crystalloids in fine needle aspirates of salivary gland adenomas.

OBJECTIVE: To evaluate the presence of tyrosine-rich crystalloids (TRC) in fine needle aspiration (FNA) specimens of pleomorphic adenomas of salivary gland. STUDY DESIGN: FNA specimens from 12 patients were reviewed, and the percentage of cases showing TRC was established. The staining properties of the TRC were evaluated as well as spontaneous fluorescence under ultraviolet (UV) light. RESULTS: Of the 12 pleomorphic adenomas, 4 showed TRC (30%) in the smears. Among the eight cytologically negative cases there were two that showed a few TRCs on histology. All positive cases were from African American patients. TRC stained weakly with Papanicolaou stain. TRC were deep blue with Diff-Quik. They fluoresced under UV light. CONCLUSION: TRC could be detected in FNA specimens. They were best seen under UV light. The Papanicolaou technique stained TRC very pale, making them difficult to see. Diff-Quik stained TRC dark blue, mimicking deposits of dye. The amount of TRC in histology paralleled the detection rate in cytology.

Significant reduction in the rate of false-negative cervical smears with neural network-based technology (PAPNET Testing System).

False-negative cervical Pap smears may lead to disability or death from carcinoma of the uterine cervix. New computer technology has led to the development of an interactive, neural network-based vision instrument to increase the accuracy of cervical smear screening. The instrument belongs to a new class of medical devices designed to provide computer-aided diagnosis (CADx). To test the instrument's performance, 487 archival negative smears (index smears) from 228 women with biopsy-documented high-grade precancerous lesions or invasive cervical carcinoma (index women) were retrieved from the files of 10 participating laboratories that were using federally mandated quality assurance procedures. Samples of sequential negative smears (total 9,666) were retrieved as controls. The instrument was used to identify evidence of missed cytological abnormalities, including atypical squamous or glandular cells of undetermined significance (ASCUS, AGUS), low-grade or high-grade squamous intraepithelial lesions (LSIL, HSIL) and carcinoma. Using the instrument, 98 false-negative index smears were identified in 72 of the 228 index women (31.6%, 95% confidence interval [CI]: 25% to 38%). Disregarding the debatable categories of ASCUS or AGUS, there were 44 women whose false-negative smears disclosed squamous intraepithelial lesions (SIL) or carcinoma (19.3%; 95% CI: 14.2% to 24.4%). Unexpectedly, SILs were also identified in 127 of 9,666 control negative smears (1.3%; 95% CI: 1.1% to 1.5%). Compared with historical performance data from several participating laboratories, the instrument increased the detection rate of SILs in control smears by 25% and increased the yield of quality control rescreening 5.1 times (P < 0.0001). These data provide evidence that conventional screening and quality control rescreening of cervical smears fail to identify a substantial number of abnormalities. A significant improvement in performance of screening of cervical smears could be achieved with the use of the instrument described in this report.

Accuracy of fine needle aspiration biopsy of the breast.

Fine needle aspiration biopsy (FNAB) has become a widely used and accepted procedure to detect benign and malignant lesions of the breast. In the past, highly invasive procedures were used in the investigation of suspect breast tumors. Surgical excision was the method of choice during this period often requiring hospitalization of the patient. However, the recent introduction of FNAB has allowed a less traumatic approach for such investigations. Due to pressures from Health Management Organizations (HMO's), FNAB is presently the method of choice allowing for decreased patient trauma, expense, and ability of the procedure to be performed on an outpatient basis. Although highly accepted by most clinicians, others suggest that FNAB should perform diagnostically at a level equivalent or higher than that obtainable by frozen tissue sectioning procedures. This study was designed to evaluate the diagnostic ability of FNAB. Four-hundred twenty-seven patients underwent FNAB during 1993-94 at the University of Mississippi Medical Center. Of those patients, two hundred thirty-seven also underwent corresponding surgical biopsies. Sensitivity (88%), specificity (96%), a false positive rate (4%), and a false negative rate (12%) were calculated from the data and reported. In conclusion, the diagnostic accuracy of FNAB of the breast determined in this study shows the significance of the procedure.

Abnormal cervical lesions in young adults.

The objective of this study is to determine the prevalence of cervical lesions in a population of young adults. This study took into account 897,900 pap smears kindly provided by the cytopathology division at the University of Mississippi Medical Center. These cases were subdivided into three different groups based on age. Group one represents the age population of 0-17, group two represents the age population of 18-34, and group three represents the age population of 35 and higher. Seven different parameters were evaluated in this study. These include negative: unsatisfactory, atypia, CIN I, CIN II, CIN III, and invasive carcinoma. Data obtained from this study suggests that cervical lesions among young teenagers were found to be significant and our observations recommend that this population be screened and evaluated on a regular basis. The results of this study conclude that cervical lesions are significant among young adults. This age group would benefit from education and routine screening. In addition early sexual activity, multiple partners, and infectious diseases were noted in cases with cervical cancer. This could be due to the high occurrences of SIL in young adults. Screening of this age group is highly recommended for those young adults at "high risk."

Reactive cell change in cervicovaginal smears.

Reactive cell change in cervicovaginal smears is a controversial issue. The most common criteria for reactive cell change include an increase in nuclear size, presence of nucleoli, binucleation, cytoplasmic vacuolization, and polychromasia. The purpose of this study is to define, as specifically as possible, the criteria of reactive cell change. Sixty-one cervicovaginal smears in a routine examination obtained during 1988 to 1994 were reviewed for this study. All cases had been diagnosed as reactive. Fifty-three of these were re-diagnosed as reactive and 8 cases were rediagnosed as negative. Inflammatory cells were present in 79% and organisms involvement such as Herpes, Trichomonas, Chlamydia, Gardnerella, and Candida were present in 23% percent. The smears were also evaluated for cellular arrangement, origin of the reactive cells, and presence of nucleoli. The majority of reactive cells were found in aggregates and were of metaplastic origin. Nucleoli were present in 85% of the cases. In all cases the most important criteria of reactive cell change were found to be aggregates of metaplastic cells with central nuclei containing nucleoli and a fine chromatin pattern, followed by the presence of organisms. Additionally, the majority of cases with a cytology diagnosis of reactive cell change had a squamous intraepithelial lesion on biopsy. In conclusion, this study suggests that follow-up Pap smears over a two year period may revert to normal in some of the cases.

Follicular carcinoma arising in ectopic thyroid tissue: case report with fine-needle aspiration findings.

A 32-yr-old woman was found to have a 1 x 2 cm mass in the soft tissue of the neck 1 cm lateral to the left lobe of the thyroid gland. A fine-needle aspiration biopsy showed a follicular neoplasm. The excised mass showed a follicular carcinoma arising in lateral ectopic thyroid tissue. Subsequent excision of the thyroid gland and pathological examination showed no primary carcinoma in the gland. This report illustrates a case of primary follicular carcinoma arising in a lateral ectopic thyroid tissue in the neck.

Nodular hematopoiesis of the liver diagnosed by fine-needle aspiration cytology.

A case of tumor-like extramedullary hematopoiesis (EMH) of the liver diagnosed by fine-needle aspiration cytology guided by computer tomography (CT) is reported. The initial clinical diagnosis was metastatic carcinoma from an adrenal gland primary. Five other cases of tumor-like EMH diagnosed by FNA have been presented in the literature. In two of the cases, the primary clinical diagnosis was metastatic tumor. The most common location for tumor-like EMH is paravertebral and intrathoracic. Three such cases of paravertebral tumor-like EMH have been diagnosed by FNA. Nodular EMH can be found rarely in other organs as in the liver.

Bronchoalveolar lavage for diagnosis of fungal disease. Five years' experience in a southern United States rural area with many blastomycosis cases.

OBJECTIVE: To determine the relative frequency of Blastomyces dermatitidis among other microorganisms in bronchoalveolar lavage (BAL) specimens. STUDY DESIGN: The study group consisted of 208 BAL specimens received from 192 patients from March 1988 to August 1993. RESULTS: Forty-seven specimens from 42 patients were positive for pathogenic microorganisms, and 2 other specimens were diagnostic of malignancy. Pneumocystis carinii (23 specimens) was the most common microorganism found in the specimens. Candida spp (10 specimens) was the second most common microorganism, and B dermatitidis (5 specimens) was the third. Cryptococcus neoformans (3 patients), Histoplasma capsulatum (2 patients) and Conidiobolus coronatus (1 patient) were the other fungi detected in BAL. Acid-fast bacilli, cytomegalovirus and herpes simplex virus were also found (1 patient each). Several patients had more than one organism. CONCLUSION: B dermatitidis was the third most common microorganism found in BAL specimens at our hospital.

Practical approaches to screening for cervical cancer.

The Program of the Fundação "Centro de Pesquisa de Oncologia" (FCPO) and the Instituto Brasileiro de Controle do Câncer (IBCC) in São Paulo has examined 980,977 women from 1970 to September 1985. Dysplasias, in situ, and invasive carcinomas were detected in 15,123 women (1.5%). The rates of false-negative and false-positive cytologic diagnoses of the program are 2.3% and 27%, respectively. The following epidemiological variables were evaluated: age, parity, age at first sexual intercourse, age at first pregnancy, education, and age at menarche. It was found that women at higher risk for cervical carcinoma in this population were those 26 years of age or older, with 4 or more pregnancies, women who had the first coitus before 18 years of age, and the first complete pregnancy before 19, as well as illiterate women or those who did not complete the first 4 years of primary school. In Brazil, the frequencies of cervical carcinomas are 25.8% for in situ and 72.2% for invasive (0.4 to 1). In this program, the corresponding percentages are 61.0% for in situ and 39.0% for invasive carcinomas (1.6 to 1). Including dysplasias, the percentages for Brazil are 56.3% for severe dysplasias plus in situ carcinomas and 43.7% for invasive carcinomas (1.3 to 1). In the FCPO/IBCC Program these percentages are 83.2% and 16.8% (5 to 1).

Carcinoembryonic antigen. A possible predictor of recurrence in cystosarcoma phyllodes.

Tissue carcinoembryonic antigen (CEA) and cytosolic estrogen and progesterone receptors were studied in 15 patients with cystosarcoma phyllodes (CSP) aiming at predicting recurrence of the tumor. Polyclonal (rabbit, monospecific) and monoclonal (mouse) antibodies anti-CEA were applied to formalin-fixed, paraffin-embedded tissue sections using an indirect (PAP) immunoperoxidase method. Estrogen receptors (ER) and progesterone (PR) receptors were determined by a charcoal-dextran method. ER was detected in 4 of 15 primary CSP (mean level, 22 fmol/mg protein). CEA was demonstrated exclusively in the epithelial components of 12 of 15 tumors. Strong expression of CEA was verified in eight tumors, six of which recurred locally one or more times. None of the seven tumors negative or weakly reactive for CEA had recurrences. No correlation was found between expression of tissue CEA and steroid receptor status of the tumors. Our data indicate that strong CEA expression in CSP correlates with tumor recurrence.

Steroid receptors in breast angiosarcoma.

The presence of receptors for estrogen, glucocorticoid and progesterone was determined in the cytosol of two breast angiosarcomas. Estrogen and glucocorticoid receptors were present in both of them. Progesterone receptors were present in one of the two tumors assayed. Occupied nuclear estrogen receptors have been found in the nuclear extracts of both tumors. Unoccupied nuclear receptors were found only in the progesterone-positive tumor. Density gradient analysis suggested that glucocorticoid and estrogen bindings were located predominantly in the 6S and 7 to 8S regions, whereas receptor for progesterone sedimented at 4S.