Inguinal cord cysts.

Inguinal cord cysts are found in less than 1% of inguinal hernia dissections. They are benign masses anatomically distinct from scrotal hydroceles that frequently mimic incarcerations or may have unusual tissue components; therefore it is recommended that they be removed when encountered to prevent future symptoms. Five cases of male inguinal cord cysts treated by the same surgeon are reviewed.

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Contamination of cerebrospinal fluid specimens with hematogenous blasts in patients with leukemia.

Hematogenous blasts in cytologic preparations of cerebrospinal fluid (CSF) have generally been thought to indicate leukemic involvement of the central nervous system (CNS). However, two leukemic patients who came to autopsy had no CNS involvement despite positive CSF preparations shortly before death. Both patients had over 10,000 blasts/cu mm in their peripheral blood. The CSF specimen from one patient was grossly bloody, but the specimen from the second patient was clear. An experiment was designed to test the hypothesis that membrane filter techniques are sufficiently sensitive to detect blasts in CSF contaminated by amounts of leukemic blood too small to be detected visually. Blood from a leukemic patient with 130,000 cells/cu mm was serially diluted in CSF from 1:20 to 1:1,600,000 and membrane filters from each dilution were examined. No blood could be detected visually at the 1:8,000 and further dilutions. Blasts forms were seen on membrane filter preparations down to the 1:1,600,000 dilution, which contained 0.000000125 ml of blood, equivalent to about 1/40,000th the volume of an 18-gauge spinal needle. These findings suggest that contamination of CSF specimens with minute amounts of blood, undetectable by visual inspection, may lead to erroneous interpretation of leukemic involvement of the CNS.

Infantile pulmonary hypertension associated with foreign body vasculitis.

An infant dying with pulmonary hypertension had a pulmonary vessel foreign body vasculitis as identified by light microscopy and characterized ultrastructurally by scanning electron microscopy and energy-dispersive x-ray analysis. The inclusions were of two distinct types: those containing silicon and titanium, and others consisting of talc. The possible sources of these inclusions and the importance of considering foreign body vasculitis in the pathogenesis of clinically idiopathic pulmonary hypertension are discussed.

Apocrine differentiation in human mammary carcinoma.

Six invasive carcinomas that contained apocrine differentiation as the primary morphologic pattern were selected from a series of 1500 prospectively examined breast carcinomas (0.4%). While apocrine features were seen in many breast tumors, these six cases were identified by uniformly fine granular, pale, eosinophilic cytoplasm with apical cytoplasmic projections similar to that seen in apocrine metaplasia. In each example, ultrastructural analysis revealed the presence of numerous 400-600 nm membrane bound vesicles with dense homogeneous osmophilic cores. These granules clustered toward the apex of the cytoplasm in the majority of the epithelial cells. All six tumors were deficient in high-affinity, low-capacity 8S estrogen and progesterone proteins, while a high-capacity, low-affinity, nonsaturable 4S progesterone-estrogen binding protein was observed. Cortisol did not bind to this protein. These observations characterize the ultrastructure of apocrine carcinoma as a variant of human mammary carcinoma.

Correlation of estrogen and progesterone receptors with histologic differentiation in mammary carcinoma.

Using a modification of the histologic grading system of the NSABP, we observed a trend towards higher levels of estrogen (E2R) and progesterone receptor (PR) content in well (grade I) and moderately (grade II) differentiated mammary carcinomas. This relationship between receptor content and histologic grade is enhanced by considering estrogen and progesterone receptor simultaneously. The rank correlation between the quantitative levels of E2R and PR was 0.74 among histologic grade I tumors and 0.64 among histologic grade II tumors. Among the grade III carcinomas, the majority of tumors displayed either a paucity of measurable receptor or a divergence between levels of estrogen versus progesterone receptor (r = 0.19). The use of ultrastructural evaluation of features of differentiation is discussed in the evaluation of grade III tumors and in the evaluation of specific histologic types of mammary carcinoma.

Comparison of sex steroid receptor analyses and carcinoembryonic antigen with clinical response to hormone therapy.

This study corroborates previous reports which suggested the efficacy of estrogen receptor (ER) analysis in predicting responses of patients with metastatic mammary carcinoma to hormonal therapeutic manipulation. The predictive value of multiconcentration titration and sucrose density gradient analyses of ERs and progesterone receptors (PRs) are compared. The predictive value of ER analyses can be improved by the discrimination of 8S versus 4S binding species or by the use of PR analysis in combination with ER analysis. The tumor-associated antigen, carcinoembryonic antigen (CEA), is evolving as an important quantitative aid in evaluating the clinical responses to patients receiving hormonal therapy.

Cytologic detection of hepatic metastases.

Cytologic preparations and histologic specimens from 404 liver biopsies were reviewed. The cytologic specimens were prepared from the saline rinsings of the Klatskin biopsy needle. Malignant neoplasms were detected by both methods in 50 cases. In seven cases, neoplasms were diagnosed by cytologic techniques alone; in nine cases neoplasms were present in the biopsy only. No false-positive cytologic diagnoses of malignancy occurred. The results of this study show that cytologic examination of the rinsings of the biopsy needle is a sensitive and highly specific adjunct to biopsy in the detection of hepatic metastases.

Conservative management of the Zollinger-Ellison syndrome. Ectopic gastrin production by an ovarian cystadenoma.

Techniques for evaluating ectopic gastrin production associated with the Zollinger-Ellison syndrome are described. The site of gastrin production in this example was a mucinous cystadenoma of the ovary confirmed by immunoperoxidase localization of gastrin within the ovarian tumor cells and by radioimmunoassay of the tumor's gastrin content. These methods, localizing the source of ectopic gastrin, permitted conservative management of the ulcer diathesis with surgical resection of the mucinous cystadenoma. After oophorectomy the patient's serum gastrin level returned to normal, and the ulcer diathesis ceased.

Recurrent arteriotracheal fistula.

A 28-year-old man with a tracheostomy had two episodes of hemorrhage from an arteriotracheal fistula secondary to erosion of the cannula tip into the right subclavian and the right common carotid arteries. Arteriotracheal fistual formation is associated with high pressure cuffs, low tracheostomies, excessively long or curved tracheostomy tubes, mediastinal infections, and superiorly placed anatomic variants of the innominate artery. Repeat fistula formation can be anticipated until the underlying factor is eradicated.

Selection of patients for heterotopic implantation of the areola and nipple.

In a prospective analysis of 291 specimens taken at mastectomy for carcinoma, 48 contained tumor in the nipple-areola complex. The characteristics of greater tumor size, higher frequency of lymph node involvement, midbreast tumor location and multifocality of tumor correlated well with the probability of involvement of the nipple. The findings emphasize the importance of close clinical and histopathologic examination of the nipple and areola when preservation of the nipple is being considered.

Clinical correlates of estrogen- and progesterone-binding proteins in human endometrial adenocarcinoma.

Seventy-eight endometrial carcinoma specimens from 74 patients were evaluated for estrogen (E2R) and progesterone (PrR) receptors by multiconcentration saturation and sucrose density gradient analysis. The clinical stage and histologic grade of the tumors and the patients' clinical course were compared to the qualitative and quantitative evaluations of E2R and PrR. Although no correlation was seen between receptor content and extent of disease, tumors with significant levels of E2R and PrR tended to be less aggressive than those in which neither receptor was detected. The histologic grade correlated with a combination of estrogen and progesterone receptor content. In 92% of the patients there was a concordance between the presence or absence of E2R and PrR in the tumor and a clinical response to progestin therapy. The significance of these findings in relationship to the presence of multiple forms of steroid binding is discussed.

Tonsillar metastasis from carcinoma of the breast with ultrastructural and steroid receptor analyses.

An unusual site of metastasis for mammary carcinoma is presented with an examination of the tumor's histologic and ultrastructural features, as well as its estrogen and progesterone receptor protein content. The importance of careful examination of the tonsillar area is emphasized in this patient in whom the tonsillar metastasis represented the initial indication of breast tumor recurrence. Estrogen and progesterone receptor analyses are utilized both as an aid in identifying the origin of the metastatic tumor focus as well as an aid in selecting therapy.

PIP: A case report and an ultrastructual study are published together to elucidate an unusual site of metastasis for mammary carcinoma. A 33-year-old American Indian mother presented with a left tonsillar mass; 11 months before she had undergone a right simple mastectomy for an apparently localized carcinoma of the breast. Biopsy material from the tonsillar mass contained carcinoma, and an axillary mass was subsequently excised and noted to contain similar tumor. After oophorectomy, the patient experienced remission of her bone pain and reduction in liver size. 5 figures form the bulk of the ultrastructural study. Histologically the tumor from the original mastectomy represented a medullary variant of infiltrating ductal carcinoma of the breast; the specimen was characterized by sheets of large bizarre, pleomorphic cells with hyperchromatic, pleomorphic nuclei and frequent mitosis. Only slight glandular differentiation of scirrhous reaction was apparent. The tonsillar biopsy contained several nodules of metastatic carcinoma with minimal adenomatous differentiation, bisicular nuclei, and prominent nuclei. Ultrastructurally, both metastatic foci of tumor were similar and characterized as adenocarcinomas with well-developed endoplasmic reticulum, cytoplasmic vacuolization, osmophilic granules, intracellular canaliculi with microvilli, numerous desmosomes, large nuclei with marginated nuclear chromatin, and enlarged nuceoli. Mitotic figures were abundant.

Cystosarcoma phylloides. A steroid receptor and ultrastructure analysis.

Six cases of cystosarcoma phylloides were evaluated by ultrastructure and steroid receptor analysis. Electron microscopy of the lesions supported previous reports of a heterogeneous tumor consisting of pleomorphic mesenchyme and normal or proliferative epithelium. In each case estrogen and progesterone receptor analysis indicated the presence of a nonsaturable estrogen and progesterone 4S binding protein rather than a specific steroid receptor as suggested by previous studies.

Correlation of estrogen and progesterone receptors with histologic differentiation in endometrial adenocarcinoma.

Endometrial carcinomas from 58 patients were graded histologically, and the histologic grade was compared with the estrogen and progesterone receptor content of the tumor tissues. Receptor content was determined by multiple concentration saturation analysis and sucrose density gradient analysis. A positive correlation was found between the presence of estrogen and progesterone receptors and the degree of tumor differentiation. The majority (85%) of well-differentiated lesions contained significant amounts of both steroid receptor proteins. In contrast, only 13% of the poorly differentiated lesions were characterized by the presence of detectable levels of both estrogen and progesterone receptor proteins. The relationship of receptor content and degree of differentiation to prognosis and potential for response to hormonal therapy is discussed.

PIP: The histologic grade of endometrial carcinoma is compared with the quantitation of both estrogen and progesterone receptor proteins. 58 patients of 100 consecutive cases of endometrial neoplasia seen at Duke University Medical Center had adequate tissue for complete evaluation. The study covered a 22-month period from September 1, 1976 to July 1, 1978. The patient population ranged in age from 28-92 years and had both locally invasive and metastatic endometrial neoplasia. Receptor content was determined by multiple concentration saturation analysis and sucrose density gradient analysis. A positive correlation was found between the presence of estrogen and progesterone receptors and the degree of tumor differentiation. 85% of well-differentiated lesions contained significant amounts of both steroid receptor proteins while only 13% of poorly differentiated lesions were characterized by the presence of detectable levels of both estrogen and progesterone receptor proteins. Attention is directed to the relationship of receptor content and degree of differentiation to prognosis and potential for response to hormonal therapy.

Gonadal dysgenesis with adenocarcinoma of the endometrium: an electron microscopic and steroid receptor analyses with a review of the literature.

A patient with gonadal dysgenesis who developed endometrial carcinoma in her 31st year of estrogen therapy is discussed in relation to thirteen previously reported cases of carcinoma of the uterus in patients with Turner's syndrome. The pattern of steroid receptor proteins in the endometrial carcinoma was found to correlate with the degree of differentiation of the tumor as assessed by light and electron microscopy. The findings reflect a potential for continued hormonal responsiveness of the tumor.