[Blast-like tumor tissue in cervical lymph node with expression of placental alkaline phosphatase]. / Blastäres Tumorgewebe in Halslymphknoten mit Expression plazentaalkalischer Phosphatase.

We report a case of ALK1-positive anaplastic large cell lymphoma with expression of placental alkaline phosphatase (PLAP) in many tumor cells. Initially, due to the positivity of tumor cells for CD30 and PLAP, lymph node metastasis of a germ cell neoplasm was discussed. Anaplastic large cell lymphomas of T­cell lineage form a group of rare non-Hodgkin lymphomas with heterogeneous morphological and immunohistochemical appearance. They may imitate other neoplasms, such as large cell B­cell lymphomas, metastasis of a carcinoma, melanoma, embryonal carcinoma or seminoma, rhabdomyosarcoma and inflammatory myofibroblastic tumor. Only an extended immunohistochemistry panel leads to an accurate diagnosis.

[Retroperitoneal bronchogenic cyst]. / Retroperitoneale bronchogene Zyste.

We describe a 35-year-old female patient who underwent surgery because of a coincidentally occurring cryptic tumour near the left adrenal gland and a right renal carcinoma (pT1, N0, G2, R0). The left-sided tumour was intraoperatively identified as a cystic structure filled with secretion. Histopathological analysis provided the diagnosis of a bronchogenic cyst.

[The infammatory pseudotumour -- an unusual liver tumour]. / Der inflammatorische Pseudotumor -- eine schwierige Differenzialdiagnose.

We report on a 49-year-old male patient who was suspected to have a malignant liver tumour with enlarged perihepatic lymph nodes because of CT and ultrasound scanning. To verify the diagnosis and procure a histological specimen, the patient underwent laparotomy. Histologically, an inflammatory pseudotumour could be confirmed. This is a rare disease which can present with fever, abdominal pain, vomiting and weight loss indicating malignancy or abscess. The definite diagnosis is often only verified by surgery.

Differentiation of focal nodular hyperplasia and hepatocellular adenoma by contrast-enhanced ultrasound.

Non-invasive differentiation of focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA) is difficult. The aim of this study was to assess the accuracy of contrast-enhanced phase inversion ultrasound to differentiate between histologically proven FNH and HCA, analysing the arterial and (early) portal venous phase. 32 patients with histological proven FNH (n=24) or HCA (n=8) have been included in this prospective study. Examination technique: Siemens Elegra, phase inversion harmonic imaging (PIHI) with low mechanical index (MI)<0.2-0.3 using SonoVue (BR 1). The contrast enhancing tumour characteristics were evaluated during the hepatic arterial (starting 8-22 s) and early portal venous phase (starting 12-30 s). The image analysis was performed by three examiners. In 23 of 24 patients with FNH the contrast pattern revealed pronounced arterial and (early) portal venous enhancement. Homogeneous enhancement was detected during the hepatic arterial phase in all eight patients with HCA. In contrast to patients with FNH, no enhancement was seen during the portal venous phase. In conclusion, contrast-enhanced phase inversion ultrasound demonstrated pronounced arterial and portal venous enhancement in patients with focal nodular hyperplasia. In contrast, after homogeneous enhancement during hepatic arterial phase, no enhancement during hepatic portal venous phase was detected in patients with hepatocellular adenoma. Therefore, this technique might improve the functional characterization of benign hypervascular focal liver lesions.

Improved characterisation of histologically proven liver tumours by contrast enhanced ultrasonography during the portal venous and specific late phase of SHU 508A.

PURPOSE: Ultrasound is reported to be relatively unreliable in the characterisation of liver tumours. The purpose of this study was to assess the ability of contrast enhanced phase inversion ultrasound (PIUS), a new highly sensitive contrast specific technique, performed during the liver specific phase of Levovist, to differentiate between benign and malignant lesions of the liver. PATIENTS AND METHODS: A total of 174 patients with histologically proven liver tumours were prospectively examined with conventional B mode ultrasound and two minutes after intravenous bolus injection of SHU 508A (Levovist). The examination technique comprised: Siemens Sonoline Elegra, phase inversion harmonic imaging (ECI); high mechanical index (1.2-1.7) using a delayed two minute post contrast scanning technique. RESULTS: In all patients with malignant disease, hypoechoic contrast enhancement was seen during the portal venous phase, and convincing but variably less demarcated in 13 patients with hepatocellular carcinoma compared with all patients with liver metastases. The liver tumours proved to be histologically benign in 95 patients and malignant in 79 patients. Homogenous contrast enhancement with a mainly isoechogenic appearance in the portal venous and liver specific late phase was seen in almost all patients with benign liver lesions with the exception of one patient with an inflammatory pseudotumour of the liver and five patients with abscesses. These six exceptions all demonstrated a hypoechoic appearance in the portal venous and liver specific late phase. DISCUSSION: The ability of unenhanced ultrasonography to characterise liver disease is known to be limited. PIUS performed during the portal venous and liver specific late phase of Levovist may differentiate between benign and malignant liver tumours in most cases, with the exception of, for example, abscesses, scars, necrosis, cysts, and calcifications, which need to be excluded clinically and by conventional B mode ultrasonography.

[MRI staging of prostate cancer with the combined endorectal body phased-array coil and histologic correlation]. / Kernspintomographisches Staging des Prostatakarzinoms mittels kombinierter Endorektal-Body-Phased-Array-Spule und histopathologische Korrelation.

PURPOSE: Evaluation of the diagnostic value of the combined endorectal body-phased array technique regarding the staging of prostate cancers, especially in the differentiation between stages T2 and T3. MATERIALS AND METHODS: Forty-two patients with biopsy-proven or clinically suspected prostate cancer were examined on a 1.5 T scanner (Siemens, Symphony) prior to radical prostatectomy. T (2)-weighted TSE (axial, coronal) and T (2)-weighted FSE (axial) sequences were obtained with and without fat suppression. After application of 0.2 mmol/kg body-weight Gd-DTPA, T (1)-weighted GRE sequences were obtained using dynamic MRI. All images were prospectively interpreted by two observers. The MR images were correlated with the histopathological findings of wide-area sections of prostatectomy specimens. RESULTS: For the detection of extracapsular growth and seminal vesicle infiltration (T2 versus T3) the accuracy was between 94 % and 97 % (sensitivity 100 %, specificity between 87 % and 93 %, observer 1 and 2). In two cases with a histologically proven stadium pT2b, observer 1 had diagnosed stadium pT3a. The results of observer 2 were marginally better in only one case, which was histologically proven to be pT2b and overstaged as pT3a. MRI did not lead to under-staging of a single tumor with regard to the differentiation between T2 and T3. Overall, the staging of the tumor stages (T1 - T4) was correct in 25 of 33 cases (75 %). The dynamic MRI showed no improvement regarding sensitivity (100 %) and specificity (62 %) and achieved a staging accuracy of only 75 %. CONCLUSION: MRI performed with a combination of a pelvic phased-array coil (PPA) and integrated endorectal coil plays a significant role in the preoperative staging of prostate cancer. However, differentiation between capsular infiltration (T2) and penetration (T3) as well as evaluation of the seminal bladder (T3b) seem to be difficult.

Right hemihepatectomy for bile duct injury following laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) has become the treatment of choice for patients with symptomatic cholecystolithiasis. But with the introduction of this technique, the incidence of bile duct injuries has increased. We report the case of a 33-year-old man who was transferred from an affiliated hospital to our department for the treatment of a bile duct injury 2 weeks after LC. Prior to transfer, a laparotomy had been performed, with insertion of a T-tube and a Robinson drain on day 5 after LC. Endoscopic retrograde cholangiography (ERC) on admission day revealed an extensive defect of the right biliary system, which could not be treated endoscopically. An emergency laparotomy had to be performed at night for acute bleeding from the portal vein. Due to massive inflammation in the porta hepatis and intraparenchymal destruction of the right bile duct, liver resection was performed 2 days later, after the patient had stabilized in the intensive care unit (ICU). The patient had a prolonged postoperative course, but he finally recovered well from these operations. In conclusion, the management of bile duct injuries should include ultrasound to detect and drain fluid collections and ERC to classify the injury. Emergency laparotomy should never be performed without these examinations, since the majority of bile duct injuries can be treated endoscopically. Surgery for this serious complication should always be performed at specialized centers for hepatobiliary surgery.

Nodular regenerative hyperplasia of the liver: a rare differential diagnosis of cholestasis with response to ursodeoxycholic acid.

Nodular regenerative hyperplasia of the liver (NRHL) is an uncommon non-malignant finding typically associated with haematological or auto-immune disease. The main clinical symptom is portal hypertension in the absence of underlying liver cirrhosis. The pathogenesis of NRHL remains unknown. We report a case of NRHL with cholestasis and progression to liver insufficiency without any underlying disease and no association with systemic disease or drug intake. Cholestasis and liver function tests improved significantly during treatment with ursodeoxycholic acid (750 mg per day). Based on this case, it may be concluded that treatment with ursodeoxycholic acid might be beneficial in patients with NRHL and progression to liver insufficiency.

An unusual cutaneous T cell lymphoma presenting as leonine facies.

We report an unusual case of a cutaneous T cell lymphoma with the clinical picture of leonine facies as the only skin symptom appearing during the first years of the disease. Small atypical lymphocytes with partly pleomorphic, partly indented cerebriform nuclei are present in the facial skin as well as in the peripheral blood and in the bone marrow. The lymphoma shows an indolent clinical behaviour without rapid progression of the disease. It shares features with both pleomorphic small/medium-sized T cell lymphoma and mycosis fungoides, but cannot be classified according to the criteria of the European Organization for Research and Treatment of Cancer (EORTC) Classification for Primary Cutaneous Lymphomas. At present the lymphoma has to be ranged among the group of so-called unspecified peripheral T cell lymphomas according to the proposal of the International Lymphoma Study Group.

[Diagnostic value of stomach biopsy in comparison with surgical specimen in gastric B-cell lymphomas of the MALT type]. / Diagnostische Aussagekraft der Magenbiopsie im Vergleich zum Resektat bei primären gastralen B-Zell-Lymphomen vom MALT-Typ.

Diagnostic und therapeutic management of gastric lymphomas of the mucosa-associated lymphoid tissue type (MALT-type lymphomas) is often based exclusively on the evaluation of biopsy material. To evaluate the diagnostic value of gastric biopsies in gastric MALT-type lymphomas, biopsies--on average six per patient--and subsequent surgical specimens of 64 patients were compared at the Institute of Pathology, University of Würzburg. Tumor diagnosis and tumor gradind were assessed. Using biopsy specimens, primary gastric MALT-type lymphomas were correctly diagnosed by local pathologists in 69% of cases, but correctly graded as low-grade, high-grade or secondary high-grade lymphomas in only 41%. When immunohistochemistry and molecular biological techniques were applied in addition to conventional histology, diagnosis of gastric MALT-type lymphoma was achieved in biopsies in 95% of cases at the Institute of Pathology Würzburg, but correct grading in only 73%. In secondary high-grade MALT-type lymphomas, both components--the high-grade and the low-grade component--were identified in gastric biopsies in only 33% of cases. Diagnostic accuracy in gastric lymphomas based on biopsies is limited by biopsy artefacts, but improved by using immunohistochemistry and molecular biological techniques. Particularly in secondary high-grade MALT-type lymphomas the correct diagnosis is often missed when using biopsies, due to a low number of biopsy specimens.

Molecular evidence of bone marrow involvement in advanced case ot Tgammadelta lymphoma with secondary myelofibrosis.

We describe the case of a middle-aged man with long indolent course of generalized Tgammadelta lymphoma. The onset of secondary myelofibrosis made cytological monitoring of the bone marrow infiltrates impossible. As during progression of the disease splenectomy revealed typical histological features of a high-grade hepatosplenic Tgammadelta lymphoma, the low-grade bone infiltrate was considered a secondary lymphoma. The use of the polymerase chain reaction helped to detect a constant and identical monoclonal rearrangement pattern of the T-cell receptor gamma-chain gene in both bone marrow and splenic T-cell infiltrates. The notion of a secondary spread of malignant T-cells to the bone marrow was thereby confirmed despite striking cytological differences between bone marrow and splenic infiltrates. This is the first report of a diagnostic DNA-based molecular approach using fixed decalcified bone marrow. This method may provide a major tool when dealing with myelofibrosis, which normally hampers sampling of cytological specimens.

[Polyposis of the gastrointestinal tract as a manifestation of diffuse follicular lymphatic hyperplasia]. / Polypose des Gastrointestinaltraktes als Manifestation der diffusen follikulären lymphatischen Hyperplasie.

HISTORY AND ADMISSION FINDINGS: A 21-year-old previously healthy Turkish man who had been living in Germany for 15 years was admitted because of worsening cramp-like abdominal pain with nausea, vomiting and watery diarrhoea. Palpation elicited diffuse muscular guarding over the entire abdomen and a mass of about 8 cm in the right lower abdomen. INVESTIGATIONS: Abnormal laboratory results were erythrocyte sedimentation rate (55 mm), C-reactive protein (6.2 mg/dl), total bilirubin (2.1 mg/dl), creatine kinase (137 U/l) and thymidine kinase (5.5 U/l). There was a slight leucocytosis (13,700/microliter) and mild anaemia (haemoglobin 13.4 g/dl) with a normal differential count. Listeria ivanovii was repeatedly cultured from stool. Ultrasonography and computed tomography of the abdomen demonstrated a 6 cm mass in the right lower abdomen, splenomegaly (15.5 x 5 cm) and several lymphomas, up to 1.8 cm in diameter. Endoscopy revealed dense, in part grass-like, polyps, 3 to 6 mm deep, in the mucosa from the terminal ileum to the rectum, and to a lesser extent also in the duodenum. Histological examination of the polyps demonstrated diffuse follicular hyperplasia without evidence of malignancy. TREATMENT AND COURSE: On antibiotic treatment with ofloxacin (2 x 400 mg intravenously) the symptoms quickly regressed, but the endoscopic findings remained unchanged. CONCLUSION: Diffuse follicular lymphatic hyperplasia manifested itself in this patient as diffuse gastrointestinal polyposis. Listeria ivanovii cannot be ruled out as a causative factor.

p53 alterations in thymic epithelial tumours.

The prognosis of thymic epithelial tumours depends on malignant behaviour that cannot always be predicted on histological grounds. This study aimed at identifying a molecular marker that would be useful in overcoming the drawbacks of histopathology. Forty-four thymic epithelial tumours were analysed for alterations of the tumour suppressor gene p53 using immunohistochemistry (antibodies D0-1 and CM-1) and PCR-based single-strand conformation polymorphism and DNA sequencing. Histological and clinical evaluation and also p53 analysis revealed three major tumour groups: non-organotypic thymic carcinomas with frequent p53 alterations (7/9) and occurrence of p53 gene mutations (2/9); malignant thymomas with frequent p53 alterations but without p53 gene mutations (11/18); and benign thymomas with rare p53 alterations and without p53 gene mutations (2/17). In non-organotypic thymic carcinomas p53 was detected with both antibodies. In contrast, thymomas lacked immunoreaction with D0-1 suggesting alteration of the antibody-binding site. Overall immunohistochemical results correlated with clinical stages (P < 0.01), pathohistology (P < 0.01), and survival times (P < 0.05). We consider immunohistochemical p53 detection to be a useful new prognostic factor for the evaluation of thymic epithelial tumours.

[Incidence and prognostic significance of epithelioid cell reactions and microcarcinoses in regional lymph nodes in stomach carcinoma]. / Häufigkeit und prognostische Bedeutung von epitheloidzelligen Reaktionen und Mikrokarzinosen in den regionären Lymphknoten beim Magenkarzinom.

The frequency and prognostic relevance of sarcoid-like lesions and microcarcinosis in regional lymph nodes in gastric cancer (n = 113; pT1-3, pN0-1, pM0, R0) were investigated; the prognostic value was compared with pT and pN stage, grading and Laurén's tumor classification with Cox's multivariate regression-model. Sarcoid like lesions were found in 34% of the cases (n = 113). Statistical analysis did not indicate that they had any prognostic value or showed whether or not microcarcinosis or metastasis was present; they were independent of pT stage, histological tumor type, tumor grading, and the clinical course of disease. Microcarcinosis (defined as scattered carcinoma cells within lymph node sinuses or pulp without adjacent stromal reaction) was revealed by immunohistochemistry in 90% of pN0 cases; the presence of 3 or more tumor cells per lymph node section in over 10% of sampled lymph nodes per case carried a significant prognostic value. In microcarcinosis without evidence of metastasis, the number of tumor cells and the number of involved lymph nodes are of prognostic value. In pN1 cases microcarcinosis was found as well as the metastases in 97% and had no additional prognostic value. Microcarcinosis alone has a different significance from lymph node metastasis for prognosis.

Pulmonary nodule caused by an alveolar adenoma of the lung.

Alveolar adenomas of the lung may be a rare cause of solitary coin lesions on chest radiographs. We report a case of this neoplasm, describe its morphological and immunohistochemical characteristics and give further evidence that alveolar adenomas of the lung represent a benign proliferation of both the alveolar epithelium and the septal mesenchyme.

Prognostic importance of histomorphologic subclassification for epithelial thymic tumors.

BACKGROUND: The prognostic importance of various clinical variables (age, sex, association with myasthenia gravis), staging according to Masaoka, histologic type according to the Marino/Kirchner/Müller-Hermelink (MKM-H) classification, and residual tumor category (R category) was evaluated in a retrospective analysis. METHODS: Eighty-two patients with epithelial thymic tumors (ETTs) treated in the period 1969-1993 were evaluated, and archived specimens were histologically reclassified according to the classification of MKM-H. RESULTS: Age, sex, and association with myasthenia gravis were of no prognostic importance. The R category is of significant prognostic importance, with 5- and 10-year survival rates of 93.6% and 87.3%, respectively, for R0 resections compared with 0% at 5 years for R1 and R2 resections (p < 0.001). Staging (Masaoka) proved to be a prognostic factor (5-/10-year survival: stage I, 100%/90.9%; II, 95%/88.2%; III, 55.9%/46.6%; and IV, 10.8%/ 10.8%; p < 0.001). Histologic typing according to MKM-H is also of significant prognostic importance (5/10 year survival: thymomas: medullary, 100%/100%; mixed, 100%/100%, predominantly cortical, 68.6%/68.6%; cortical, 65.8%/65.8%; thymic carcinomas: well-differentiated type, 62.3%/44.5%; thymic carcinomas other than well-differentiated type, 33.6%/26.9%; p < 0.001). Multivariate analysis demonstrated that staging (p < 0.001), R category (p < 0.026), and MKM-H classification (p < 0.028) have an independent impact on survival. CONCLUSIONS: Staging (Masaoka), R category, and histologic classification (MKM-H) are important independent prognostic factors for patients with epithelial thymic tumors. Complete (R0) surgical resections should be the ultimate goal in the clinical management of patients with epithelial thymic tumors.

Benefits of D2 lymph node dissection for patients with gastric cancer and pN0 and pN1 lymph node metastases.

A retrospective immunohistological analysis of 100 patients with pT1-3 N0 and pT1-3 N1 gastric adenocarcinoma demonstrated a high frequency of micro-involvement in the removed lymph nodes. The presence of three or more tumour cells in more than 10 per cent of the lymph nodes was of significant prognostic value in the pN0 cases. Multivariate analysis identified micro-involvement as an independent prognostic factor. The results explain why patients benefit from lymphadenectomy even if the removed lymph nodes are not involved by tumour (pN0) in routine histological examination. The frequent occurrence of micro-involvement is a strong argument favouring routine D2 lymph node dissection in gastric cancer surgery in patients with lymph node metastasis.

PCR-based assays for the detection of monoclonality in non-Hodgkin's lymphoma: application to formalin-fixed, paraffin-embedded tissue and decalcified bone marrow samples.

In crucial cases the diagnosis of non-Hodgkin's lymphoma (NHL) still represents a challenge to the pathologist since morphological criteria do not always help to distinguish between reactive and malignant lymphoproliferations. Clonality assays are a useful supplement since monoclonal cell proliferation is strong evidence for malignancy. The polymerase chain reaction (PCR) can be utilized to establish the clonal origin of B- or T-cell lymphocyte populations by amplification of rearranged immunoglobulin and T-cell receptor (TCR) genes. In the present study DNA was isolated from a variety of neoplastic and nonneoplastic formalin-fixed, paraffin-embedded lymph nodes (n = 62), cutaneous tissue (n = 9), samples of miscellaneous origin (n = 11), and reported here for the first time, decalcified bone marrow samples (n = 35). These samples were submitted to PCR-based assays directed against the immunoglobulin heavy-chain (IgH), immunoglobulin kappa light-chain (IgL kappa), and TCR gamma chain genes. The impact of various decalcifying agents on the ability to amplify DNA was investigated by PCR-based amplification of a single copy gene. Buffered and nonbuffered EDTA was found not to impede amplification of DNA fragments up to 300 bp in length. In lymph node and cutaneous specimens monoclonality was detected in 83% of B-NHL cases using a seminested PCR approach for the amplification of IgH, whereas the same approach gave rise to monoclonal bands in 80% of bone marrow samples. The subsequent amplification of IgL kappa helped to raise the sensitivity of detection to 94%. Monoclonality was detected in seven of nine T-cell NHLs by amplification of TCR gamma.(ABSTRACT TRUNCATED AT 250 WORDS)