Comparison of measurements of the glenopolar angle in 3D CT reconstructions of the scapula and 2D plain radiographic views.

AIMS: The aim of this study was to analyse the effect of altered viewing perspectives on the measurement of the glenopolar angle (GPA) and the differences between these measurements made on 3D CT reconstructions and anteroposterior (AP) scapular view radiographs. MATERIALS AND METHODS: The influence of the viewing perspective on the GPA was assessed, as were the differences in the measurements of the GPA between 3D CT reconstructions and AP scapular view radiographs in 68 cadaveric scapulae. RESULTS: The median GPA in 3D reconstructions and AP scapular views were 42.7° (95% confidence intervals (CI), 42.0° to 43.5°) and 41.3° (95% CI 40.4° to 42.0°) respectively (p < 0.001). All but five of 20 malpositions demonstrated a significant difference in GPA compared with the respective AP scapular view (p ≤ 0.005). The GPA was most susceptible to malposition in retroversion/anteversion. Inter- and intra-observer reliability for all measurements of the GPA was excellent for 3D CT reconstructions (intraclass correlation (ICC) 0.93 (95% CI 0.87 to 0.96) and 0.94 (95% CI 0.89 to 0.97), respectively) and higher than on AP scapular radiographs (p < 0.001). The intra- and inter-observer reliability was excellent in AP scapular views and malpositions in extension/flexion (ICC ≥ 0.84) but tended to decrease with increasing viewing angle in retroversion/anteversion. CONCLUSION: These data suggest that 3D reconstructions are more reproducible than AP scapular radiographs in the assessment of the GPA and should be used to compare data in different studies, to predict outcome, define malunion, and act as an indication for surgery in patients with a scapular fracture. Cite this article: Bone Joint J 2016;98-B:1510-16.

Cytologic features of solid pseudopapillary neoplasms of the pancreas: a single institutional experience based on evaluation of diagnostic utility of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA).

BACKGROUND: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an important modality for diagnosing solid and cystic pancreatic lesions. The objectives of this retrospective study are to review the cytologic criteria used to diagnose pancreatic solid pseudopapillary neoplasms (SPNs) and to evaluate the utility of EUS-FNA by correlating cytologic and histologic samples. CASE REVIEWS: Of the 924 pancreatic FNAs performed at our institution from January 2002 through February 2013, four histologically confirmed cases of SPN were identified; three had an initial cytologic diagnosis of SPN. All four cases lacked on-site evaluation. Cytologic smears were assessed by two reviewers for the presence of a cellular aspirate, fibrovascular stalks lined by neoplastic cells with pale to finely granular cytoplasm, and monotonous, oval nuclei containing delicate chromatin, inconspicuous nucleoli, and grooves and inclusions. Three cases were diagnosed as SPN on cytologic examination and confirmed histologically. The remaining case was deemed a pancreatic endocrine neoplasm on cytology, but SPN on final histology. The most consistent cytologic feature we encountered was the presence of a cellular aspirate containing fibrovascular stalks lined by monotonous neoplastic cells with oval nuclei and nuclear grooves. CONCLUSION: We conclude that EUS-FNA is an effective diagnostic tool in the diagnosis of pancreatic SPNs.

Histopathological, histogenetic, and immunohistochemical analysis of epidermoid cyst of spleen.

Splenic cysts are encountered not uncommonly, but large cysts occupying a significant portion of the spleen are extremely rare. We report a case of a young female patient presenting with a large epidermoid cyst involving the majority of the spleen. The patient was involved in a motor vehicle accident during which she sustained multiple rib fractures and traumatic internal organ injuries. She subsequently underwent exploratory laparotomy and splenectomy for grade III splenic lacerations. Incidentally, a 13.3 cm in greatest dimension splenic cyst replacing the majority of the splenic parenchyma was identified. Grossly, the inner lining of cyst was gray-white, smooth, and glistening. Histologically, the thick fibrous cyst wall was composed of stratified squamous epithelium, scattered foci of which were denuded. A panel of properly-controlled immunohistochemical stains was performed and showed the squamous epithelium to be strongly and diffusely immunoreactive with carcinoembryonic antigen (CEA), CA 19-9, and cytokeratin 5/6, focally immunoreactive with HBME-1, and negative for calretinin. The histomorphological features and immunohistochemical staining pattern were consistent with a diagnosis of an epidermoid cyst of the spleen.

Histological evaluation of papillary lesions of the breast from needle biopsy to the excised specimen: a single institutional experience.

BACKGROUND: The assessment and categorization of papillary lesions remains one of the most challenging areas in breast pathology. We evaluated the histological follow-up of papillary lesions of the breast from needle core biopsy to final excision to determine whether these lesions warrant excision, irrespective of histologic subtype. STUDY DESIGN: A total of 91 needle core biopsies from the breast diagnosed as "papillary lesions" at our institution from January 2001 to June 2011 were included in the study. Twenty-nine of these (mean patient age 54.93 +/- 12.5 SD) were reported as benign papillary lesions, and the remaining 62 (mean patient age 61.98 +/- 15.20 SD) were diagnosed as either atypical papillary lesions (17 cases) or malignant papillary lesions (45 cases). RESULTS. Of the 29 needle core biopsies reported as benign, 19 cases (65.5%) were diagnosed as benign and three (10.3%) were diagnosed as malignant on follow-up. The remaining seven cases did not proceed to excision. Sixty-two of the 91 cases were given a diagnosis of either atypical papillary lesion or malignant papillary lesion on needle core biopsy. Of the 45 cases initially diagnosed as malignant, 44 (97.7%) were eventually deemed malignant and one atypical ductal hyperplasia (ADH) was found upon excision. The initial diagnosis of atypical papillary lesion was rendered in 17 cases, of which 10 turned out to be malignant, five ADH, and two benign on excision. CONCLUSION: We conclude that if a benign papillary lesion is present on initial needle core biopsy, then the probability of malignancy is high (10.3%) on the final excision. Similarly, all malignant papillary lesions diagnosed on needle core biopsy should be excised due to the very high likelihood (97.7%) of a diagnosis of malignancy on final excision. Based on our results, we suggest surgical excision of any papillary lesion diagnosed on needle core biopsy.

Clear cell papillary renal cell carcinoma with characteristic morphology and immunohistochemical staining pattern.

Clear cell papillary renal cell carcinoma is newly-defined entity initially believed to be associated with end stage renal disease. We report a rare case of this neoplasm in a 70-year-old female patient with no known history of end-stage renal disease who presented with haematuria lasting several days. After initial workup, a computed tomography (CT) scan was performed and revealed a cystic mass in the right kidney. Material obtained by fine needle aspiration (FNA) biopsy of the mass was felt to be suspicious for renal cell carcinoma. The patient subsequently underwent right nephrectomy, and the lesional tissue was examined microscopically. A 2.3 cm in greatest dimension cystic space circumscribed by a fibrous wall was surfaced by a single layer of bland cuboidal cells with abundant clear cytoplasm. The solid component of the tumour consisted of branching papillae with delicate fibrovascular cores and uniformly lined by cells similar to those of the inner wall of the cyst. Some of the fibrovascular cores were markedly expanded by a myxoid-appearing substance, but no foamy cells were appreciated. Immunohistochemically, the neoplastic cells were diffusely immunoreactive with cytokeratin 7 (CK7), epithelial membrane antigen (EMA), high molecular weight cytokeratin (HMWCK) and vimentin. Neoplastic cells were only focally immunoreactive with CD10, and were negative for both p63 and alpha-methylacyl-CoA racemase (AMACR) (P504S). The cytomorphological features and immunohistochemical staining pattern of this tumour was consistent with that of clear cell papillary renal cell carcinoma (CCPRCC), as described by Gobbo et al.

High-grade primary peritoneal serous papillary carcinoma with a wide differential diagnosis: a diagnostic challenge.

Serous surface papillary carcinoma of the peritoneum is a rare malignant epithelial tumour that is histologically indistinguishable from high-grade serous papillary carcinoma of ovarian origin. We herein report a case of 66-year-old female with a history of breast carcinoma who presented with abdominal distension and shortness of breath. Imaging studies at the time of initial workup revealed multiple masses in abdominal cavity, and suspicion was high for metastatic carcinoma. The patient underwent exploratory laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy, partial colectomy, and omentectomy. Gross inspection of the omentum showed diffuse tumour caking, and frozen section evaluation of the omental nodules revealed adenocarcinoma with papillary features. Histological examination showed a high-grade papillary carcinoma with numerous psammoma bodies predominantly present within the omentum and peritoneum. Eventually, this case was determined to be a high-grade primary peritoneal serous papillary carcinoma involving the omentum, colon, and appendix, as well as the surfaces of the uterus, bilateral ovaries, and bilateral fallopian tubes. Knowledge of the primary organ of origin in cases of advanced papillary serous carcinomas is essential for both prognosis and staging, as well as for initiation of appropriate treatment. Close post-therapy follow up is required.

A functional axis based upper extremity model and associated calibration procedures.

An upper extremity model focusing on an accurate and complete description of elbow motion is introduced. Both glenohumeral center of rotation and functional elbow axes are computed and used for anatomical coordinate descriptions. Model results match goniometric measures of the flexed elbow and test-retest analyses of six subjects were repeatable within 5 degrees for most measures. The elbow axis from 25 individuals was located about 12 mm distal and anterior to the midpoint of the transepicondylar axis, placing it aligned with the center of the trochlea. Carrying angle of the elbow was determined to be 11 degrees of abduction (valgus) with the arm extended.

Germline RET 634 mutation positive MEN 2A-related C-cell hyperplasias have genetic features consistent with intraepithelial neoplasia.

C-cell hyperplasias are normally multifocal in multiple endocrine neoplasia type 2A. We compared clonality, microsatellite pattern of tumor suppressor genes, and cellular kinetics of C-cell hyperplasia foci in each thyroid lobe. We selected 11 females from multiple endocrine neoplasia type 2A kindred treated with thyroidectomy due to hypercalcitoninemia. C-cell hyperplasia foci were microdissected for DNA extraction to analyze the methylation pattern of androgen receptor alleles and microsatellite regions (TP53, RB1, WT1, and NF1). Consecutive sections were selected for MIB-1, pRB1, p53, Mdm-2, and p21WAF1 immunostaining, DNA content analysis, and in situ end labeling. Appropriate tissue controls were run. Only two patients had medullary thyroid carcinoma foci. Nine informative C-cell hyperplasia patients showed germline point mutation in RET, eight of them with the same androgen receptor allele preferentially methylated in both lobes. C-cell hyperplasia foci showed heterogeneous DNA deletions revealed by loss of heterozygosity of TP53 (12 of 20), RB1 (6 of 14), and WT1 (4 of 20) and hypodiploid G0/G1 cells (14 of 20), low cellular turnover (MIB-1 index 4.5%, in situ end labeling index 0.03%), and significantly high nuclear area to DNA index ratio. MEN 2A (germline point mutation in RET codon 634) C-cell hyperplasias are monoclonal and genetically heterogeneous and show down-regulated apoptosis, findings consistent with an intraepithelial neoplasia. Concordant X-chromosome inactivation and interstitial gene deletions suggest clone expansions of precursors occurring at a point in embryonic development before divergence of each thyroid lobe and may represent a paradigm for other germline mutations.

Clonal patterns in phaeochromocytomas and MEN-2A adrenal medullary hyperplasias: histological and kinetic correlates.

The relationship among histological features, cell kinetics, and clonality has not been studied in adrenal medullary hyperplasias (AMHs) and phaeochromocytomas (PCCs). Thirty-four PCCs (23 sporadic and 11 MEN-2A (multiple endocrine neoplasia type 2A)-related tumours, the latter associated with AMH) from females were included in this study. Representative samples were histologically evaluated and microdissected to extract DNA and evaluate the methylation pattern of the androgen receptor alleles. At least two tissue samples (from the peripheral and internal zones in each tumour) were analysed with appropriate tissue controls run in every case. The same areas were selected for MIB-1 staining and in situ end labelling (ISEL). Malignant PCCs were defined by histologically confirmed distant metastases. All monoclonal AMH nodules from the same patient showed the same X-chromosome inactivated. Six sporadic PCCs revealed liver metastases (malignant PCC) and eight additional sporadic PCCs showed periadrenal infiltration (locally invasive PCC). All informative PCCs were monoclonal, except for five locally invasive PCCs and one benign PCC that revealed polyclonal patterns. Those cases also showed a fibroblastic stromal reaction with prominent blood vessels, focal smooth muscle differentiation, and significantly higher MIB-1 (126.8+/-29.9) and ISEL (50.9+/-12.8) indices. Concordant X-chromosome inactivation in nodules from a given patient suggests that MEN-2A AMH is a multifocal monoclonal condition. A subgroup of PCCs characterized by balanced methylation of androgen receptor alleles, high cellular turnover, and stromal proliferation also shows locally invasive features.

Clonality as expression of distinctive cell kinetics patterns in nodular hyperplasias and adenomas of the adrenal cortex.

Although histopathologic criteria for adrenal cortical nodular hyperplasias (ACNHs) and adenomas (ACAs) have been developed, their kinetics and clonality are virtually unknown. We studied 20 ACNHs and 25 ACAs (based on World Health Organization criteria) from 45 females. Representative samples were histologically evaluated, and the methylation pattern of the androgen receptor alleles was analyzed on microdissected samples. Consecutive sections were selected for slide cytometry, flow cytometry, and in situ end labeling (ISEL). Apoptosis was studied by flow cytometry (nuclear area/DNA content plotter analysis) and by ISEL. Appropriate tissue controls were run in every case. Polyclonal gel patterns were revealed in 14/18 informative ACNHs and in 3/22 informative ACAs, whereas monoclonal gel patterns were observed in 4/18 ACNHs and 19/22 ACAs. Overlapping proliferation rates (PRs) were observed in both clonal groups, and apoptosis was detected only in G(0)/G(1) cells, especially in monoclonal ACNHs (3/4; 75%) and in polyclonal ACAs (2/3; 67%). Significantly higher PRs were observed in ACNHs with polyclonal patterns and G(0)/G(1) apoptosis and in ACAs regardless of clonality pattern and presence of G(0)/G(1) apoptosis. All except one ACNH (19/20; 95%) and 15/25 ACAs (60%) showed diploid DNA content, whereas the remaining cases were hyperdiploid. A direct correlation between PR and ISEL was observed in polyclonal lesions (PR = 29.32 ISEL - 1.93), whereas the correlation was inverse for monoclonal lesions (PR = -9.13 ISEL + 21.57). We concluded that only simultaneous down-regulated apoptosis and high proliferation result in selective kinetic advantage, dominant clone expansion, and unbalanced methylation patterns of androgen receptor alleles in ACNHs and ACAs.

Affective disorders: II. Recent advances in laboratory and pathogenetic approaches.

Part II of a two-part review of affective disorders covers laboratory and pathogenetic approaches. Recent developments in psychoendocrinology and sleep electroencephalography have provided the clinician with biologic procedures that may serve as ancillary laboratory tests to support the clinical diagnosis of affective illness. These laboratory markers have provided indirect evidence for disturbed limbic-diencephalic functioning in these disorders. Such disturbances in turn seem to reflect the convergence of multiple etiologic variables. Further, recent advances in pathogenetic mechanisms suggest that the clinical heterogeneity of affective syndromes derives from the interaction of predisposing genetic, developmental, and personality variables with proximate social and physiochemical stressors.

Agoraphobia following amphetamine withdrawal.

Agoraphobia, now a clinically accepted entity (DSM-III) was first described more than 100 years ago in the psychiatric literature. Recently, it has been considered a syndrome, with phobia, anxiety and depersonalization being the prominent symptoms. Its etiology is not clear and different schools of thought have given different explanations for its causation. Few reports of recent origin have have described a close association between the intake and/or discontinuation of pharmacologic agents and the onset of the syndrome. The agents implicated were the tricyclic group. Our report describes another "antidepressant," d-amphetamine, which when discontinued by our patient, was followed by the full syndrome of agoraphobia.

Lesions of the conduction system in the cat with cardiomyopathy.

Degeneration and fibrosis of the atrioventricular nodal tissue and left bundle branch, associated with cartilage of bone in the central fibrous body and fibrosis of the interventricular septal crest, were observed in 63 cats with cardiomyopathy. The cardiac lesions consisted of endocardial and myocardial fibrosis or organized endomyocarditis. Electrocardiographic, radiographic, angiocardiography, and hemodynamic changes were also observed in the cats.