Gastric marginal zone lymphoma of mucosa-associated lymphoid tissue and signet ring cell carcinoma, synchronous collision tumour of the stomach: a case report.

OBJECTIVE: To report a rare case of synchronous marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) signet ring cell carcinoma occurring as a collision tumour in the stomach. CLINICAL PRESENTATION AND INTERVENTION: A 53-year-old man was diagnosed initially with signet ring cell carcinoma of the stomach. The microscopy of the subsequent total gastrectomy revealed a collision tumour of MALT lymphoma and signet ring cell carcinoma associated with Helicobacter pylori gastritis. CONCLUSION: This case highlighted the importance of a careful evaluation of the accompanying lymphoid population in the biopsy samples of gastric adenocarcinoma and underlined the need for multiple endoscopic biopsies to detect these rare synchronous tumours.

Primary yolk sac (endodermal sinus) tumour of the vulva: a case report.

OBJECTIVE: To report a case of primary yolk sac (endodermal sinus) tumour (YST) of the vulva which is very rare and to highlight some unusual features of this tumour in the vulva. CLINICAL PRESENTATION AND INTERVENTION: A 23-year-old woman presented with a 1-month swelling in the right labium majus that was non-tender and rapidly increasing in size. The mass was excised; it grossly measured 6 × 5 × 3 cm and was firm with a grey white cut surface. Microscopically it showed features of YST. The patient returned to the clinic only after 2 months with a recurrent mass of almost the same size with ipsilateral lymphadenopathy. At that time serum α-fetoprotein showed only a mild increase (13.4 µg/l, normal: 0-10 µg/l). Further management was not possible as she decided to return to her native country for treatment. A literature review shows that local excision with lymphadenectomy followed by cisplatin-based chemotherapy is the best mode of treatment for primary YST of the vulva. CONCLUSION: This case is presented for its rarity and to highlight the fact that serum α-fetoprotein estimation may not aid in the primary diagnosis or detection of recurrence in patients on follow-up for YST arising in the vulva unlike those seen in the gonads.

Distribution of vacA and cagA genotypes of Helicobacter pylori in Kuwait.

There is considerable geographical variation in the distribution of allelic types of Helicobacter pylori. This first study from Kuwait determined the prevalence of cagA and vacA genotypes among 117 unselected patients attending a gastroenterology center. We found that whereas vacA s1 and s2 types were equally likely to be present in biopsies obtained from patients of Middle-Eastern origin, African Arabs were predominantly infected with s2 type and South-Asians the s1 type. South Asians most frequently carried the cagA positive genotype with Bangladeshis showing the highest prevalence rate of 87%.

Dark and pale cerebriform nuclei in FNA smears of usual papillary thyroid carcinoma and its variants.

The dark (hyperchromatic) cerebriform nucleus was recently described as a frequent finding in histopathology sections of papillary carcinoma of the thyroid. In the present study, we tried to determine the frequency of dark cerebriform nuclei in the fine-needle aspiration (FNA) smears of papillary thyroid carcinomas and compared it with those of other thyroid lesions, such as follicular neoplasms and benign hyperplastic lesions. In addition to the above-mentioned nuclear feature, pale (hypochromatic) cerebriform nucleus and other well-established cytomorphological criteria used in the diagnosis of papillary thyroid carcinomas were analyzed. FNA smears of a total of 102 cases comprising of 61 papillary carcinomas, 10 cases of suspicious papillary carcinomas, 12 follicular neoplasms, and 19 benign hyperplastic lesions were studied. Both the dark and pale cerebriform nuclei were found in a significantly higher number of cases of papillary thyroid carcinomas compared with follicular neoplasms (P = 0.0003 and P < 0.0001, respectively) or benign hyperplastic lesions (P = 0.0004 and P < 0.0001, respectively). Review sections available in 24 cases showed agreement between the cytopathological and the histopathological diagnoses in 18 (94.7%) of 19 papillary carcinomas. Thus, the dark and pale cerebriform nuclei can be regarded as useful cytomorphological parameters in the diagnosis of papillary thyroid carcinoma.

Epstein-Barr virus expression in Hodgkin's lymphoma in Kuwait.

The epidemiology of Hodgkin's lymphoma (HL) shows wide geographic variation in histological subtypes and in its association with the Epstein-Barr virus (EBV). The proportion of EBV positive HL is low in industrialized countries, high in non-industrialized countries and intermediate in early-industrialized countries. Reports from the Persian Gulf and Middle East are very limited. The aim of this study was to determine the epidemiology of HL in Kuwait, an early-industrialized country in the Persian Gulf, and to delineate the extent of its association with EBV. We reviewed 134 cases of HL for histological classification and demographic data. 107 cases were examined for the presence of EBV using immunohistochemistry (IHC) for the latent membrane protein I (LMPI) and in-situ hybridization (ISH) for EBVencoded RNA (EBER). 70.4% of the patients were males and 29.6% were females. The male: female ratio was 2.4:1. The mean age was 30.6 years (range, 4-71 years). Mixed cellularity HL (MCHL) was the most common subtype (45.5%), followed by nodular sclerosis (37.3%), nodular lymphocyte predominant (6.7%), lymphocyte rich (3%) and lymphocyte depletion (3%). 4.5% of cases were unclassifiable. EBV expression was seen in 56%, was significantly higher in MCHL, in children, and in males. Our findings suggest that the frequency of EBV expression in HL in Kuwait is similar to other early-industrialized countries. Further research from other countries in the Persian Gulf and the Middle East should shed more light on the epidemiology of HL and its relation to EBV in this region.

Comparison of bioactive glass, mineral trioxide aggregate, ferric sulfate, and formocresol as pulpotomy agents in rat molar.

Bioactive glass (BAG) is often used as a filler material for repair of dental bone defects. Although there is evidence of osteogenic potential of this material, it is not clear yet whether the material exhibits potential for dentinogenesis. Hence, the aim of the present study was to evaluate BAG as a pulpotomy agent and to compare it with three commercially available pulpotomy agents such as formocresol (FC), ferric sulfate (FS), and mineral trioxide aggregate (MTA). Pulpotomies were performed in 80 maxillary first molars of Sprague Dawley rats, and pulp stumps were covered with BAG, FC, FS, and MTA. Histologic analysis was performed at 2 weeks and then at 4 weeks after treatment. Experimental samples were compared with contra-lateral normal maxillary first molars. At 2 weeks, BAG showed inflammatory changes in the pulp. After 4 weeks, some samples showed normal pulp histology, with evidence of vasodilation. At 2 weeks, MTA samples showed some acute inflammatory cells around the material with evidence of macrophages in the radicular pulp. Dentine bridge formation with normal pulp histology was a consistent finding at 2 and 4 weeks with MTA. Ferric sulfate showed moderate inflammation of pulp with widespread necrosis in coronal pulp at 2 and 4 weeks. Formocresol showed zones of atrophy, inflammation, and fibrosis. Fibrosis was more extensive at 4 weeks with evidence of calcification in certain samples. Among the materials tested, MTA performed ideally as a pulpotomy agent causing dentine bridge formation while simultaneously maintaining normal pulpal histology. It appeared that BAG induced an inflammatory response at 2 weeks with resolution of inflammation at 4 weeks.

Hospital-acquired Clostridium difficile infection amongst ICU and burn patients in Kuwait.

OBJECTIVES: To prospectively study the prevalence of nosocomially acquired Clostridium difficile, a major cause of diarrhoea in hospitalized patients, in the intensive care units (ICUs) and burn unit (BUs) of three teaching hospitals in Kuwait. METHODS: During a 1-year prospective study, stool/rectal swabs were obtained from 344 patients admitted into the ICUs of Mubarak Hospital (ICU-1), the Kuwait Cancer Control Centre (ICU-2), and the BU of Ibn Sina Hospital. The presence of C. difficile and/or its toxin was detected by serially culturing the specimens on differential, selective and enriched media and the use of TOX-A/B test, on admission and at subsequent 1-weekly interval until discharge. RESULTS: Out of the 344 patients admitted into these units, over a study period of 1 year, only 263 (77%) were evaluable. All of them had negative stool culture/toxin on admission. Overall, 25 (9.5%) of these 263 patients acquired C. difficile during their hospitalization. Thirteen (7%) of 187 patients acquired C. difficile in ICU-1, 9 (36%) of 25 on ICU-2 and 3 (5.9%) of 51 patients in BU. Eight (32%) developed diarrhoea attributable only to C. difficile and/or toxin, and the remaining 17 (68%) were asymptomatic: none had pseudomembranous colitis. The diarrhoea in these patients was associated with antibiotic use, the main trigger-antibiotics being the third-generation cephalosporins. Acquisition occurred within 4-53 days of admission, with the majority occurring in the first 15 days. CONCLUSION: Overall, the prevalence of hospital-acquired C. difficile infection/colonization was less than 10%. The use of third-generation cephalosporins was high and was related to the development of diarrhoea. Once acquired, diarrhoea developed in about one third of C. difficile-positive cases, an indication that C. difficile infection/colonization endemic in the hospital ICUs studied is usually transmitted among the hospitalized patients.

Gastrointestinal stromal tumors: clinicopathological and immunohistochemical features.

OBJECTIVES: To study the clinicopathological and immunohistochemical features of gastrointestinal stromal tumors (GISTs) in Kuwait. MATERIALS AND METHODS: Hematoxylin- and eosin-stained sections of primary gastrointestinal mesenchymal tumors were reviewed. Immunohistochemical staining was performed using a panel of antibodies to determine muscle and neural differentiation, the incidence of CD117 and CD34 expression, as well as bcl-2 and cytokeratin expression. Each stain was interpreted as negative or positive. The staining intensity of positive cases was graded as weak, moderate or strong. RESULTS: The age range was 25-80 with an average age of 54 and a male:female ratio of 3:2. The stomach was the most common site for these tumors, followed by the small intestine. Histologically, 46% were classified as malignant and 54% were benign. Most of the malignant tumors occurred in males, particularly in the stomach or small intestine. There was no significant difference in patient age between malignant and benign tumors. The most sensitive markers were muscle-specific actin for muscle differentiation and glial fibrillary acidic protein for neural differentiation. CD117 expression was seen in 81% and CD34 in 54% of all tumors. CONCLUSIONS: The results of this study show that the stomach is the most common site for these tumors, that malignant tumors are more likely to occur in the small intestine than in the stomach, and that there is no difference between benign and malignant tumors with regard to age. Our findings are comparable to those of other workers, although our male:female ratio was slightly higher.

Cytodiagnosis of nipple discharge: a study of 602 samples from 484 cases.

To find out the gross and microscopic differentiating features between nipple discharges (ND) due to various breast lesions, smears of 602 ND samples from 484 cases were reviewed by one of the investigators (D.K.D.). The reviewed cytodiagnoses were as follows: benign nipple discharge (59.1%), inflammatory ND (6.5%), ?papillary lesions (2.5%), papillary lesions (20.6%), papillary lesions with atypia (3.8%), duct cells with atypia (0.2%), suspicious for malignancy (0.5%), malignant ND (1.2%), and inadequate (5.6%). Following review, samples with epithelial abnormalities (?papillary lesion, papillary lesion with and without atypia, duct cells with atypia, suspicious for malignancy, and malignancy) increased from 16.6% to 30.4% of adequate samples (P < 0.0001). 37.9% unilateral ND samples showed epithelial abnormalities, as opposed to 18.9% of bilateral ND samples (P < 0.0001). Bloodstained ND showed epithelial abnormalities in 41.5% samples, as compared to 22.1% of ND with other specified gross characteristics (P < 0.0001). The samples with epithelial abnormalities differed significantly from benign and inflammatory ND in respect of frequency of benign duct cells, duct cells with atypia, papillary clusters with or without atypia, malignant cells, columnar cells, red blood cells, inflammatory cells, and background lipid vacuoles (P < 0.01 to < 0.0001). The ND samples with suspicious and malignant cytology, besides the presence of malignant cells (P < 0.0001), differed significantly from rest of the lesions in respect of foam cells (P < 0.0001), red blood cells (P < 0.01), and inflammatory cells (P < 0.05). When compared with histopathological diagnosis in 20 cases, the benign or malignant nature of the lesion was correctly identified in ND in 80% cases. The ND cytologies in 7 histologically proved malignant cases were malignancy (3 cases), suspicious for malignancy (1 case), papillary lesion with atypia (1 case), papillary lesion (1 case), and benign ND (1 case).

Manual versus image analysis estimation of PCNA in breast carcinoma.

OBJECTIVE: To compare manual to image analysis estimation of proliferating cell nuclear antigen (PCNA) expression in paraffin sections of breast carcinomas. STUDY DESIGN: Paraffin sections of 51 breast carcinomas were stained with primary antibody to PCNA. Nuclear PCNA expression in 100 randomly selected tumor cells from marked areas was manually graded from 0 to 3. Antigen expression was also calculated by a cell analysis system (CAS-200, Becton Dickinson, Elmhurst, Illinois, U.S.A.) from marked and random microscopic fields. Obtained proliferative index (PI) from both methods was compared. RESULTS: Manually calculated PI correlated strongly with the CAS-200-calculated PI (P < .01). The highest correlation was seen between the CAS-200 PI value and manually calculated PI value using grade 2 and 3 nuclei. A particularly high correlation was noted between the number of positive nuclei and antigen staining area (P < .01) as estimated by the CAS-200. CONCLUSION: Nuclear expression of PCNA and other nuclear antigens can be accurately evaluated by an image analysis system. The speed and objectivity of such machines allow the evaluation of larger parts of tissues and provide more-representative antigen expression profiles.

Immunohistochemical study of proliferating mesenchymal spindle cells in heterogenous soft tissue lesions.

Proliferation of mesenchymal spindle cells is a main event in a variety of lesions with similar morphological features but widely divergent biological behaviour. In order to identify criteria for precise histological diagnosis, 60 human soft tissue lesions, divided into 40 cases of fibroblastic cell proliferation, 10 smooth muscle cell tumours and 10 nerve sheath cell tumours, were examined for the immunohistochemical profile of the main lesional cell in addition to other histological features. The three groups could be differentiated by determining the lineage of the constituent spindle cell on the pattern of expression of vimentin, alpha-smooth muscle actin (ASMA) and macrophage antigen CD68 (MA-CD68). Smooth muscle cells expressed ASMA and vimentin but not MA-CD68, while nerve sheath cells were negative for ASMA but positive for vimentin and MA-CD68. The fibroblastic cell lesions as a group were easily differentiated on the basis of positive reactivity for all three markers but individual lesions could only be distinguished by additional assessment of histological features. Because of consistent co-expression of ASMA, vimentin and MA-CD68 in the spindle mesenchymal cell present in all varieties of lesions in this heterogeneous group, we suggest that this proliferating "fibroblastic" cell is phenotypically a fibromyohistiocyte.

Experimental studies on multiorgan toxicity of cyclosporine-A in rats using a radiopharmaceutical and comparison with histopathological findings.

Iodine-125 HIPDM was evaluated as a screening agent for studying multiorgan toxicity due to Cyclosporine-A (CsA) and the results were compared to histopathological findings of the tissues. The rats were injected subcutaneously with 50 mg/kg (body weight) of CsA or with equal volume of the vehicle, Cremophor-EL, for 7 consecutive days. A dose of 10 microCi of I-125 HIPDM was injected intravenously at the end of the treatment period. The results indicated that there was a significant increase in the uptake of I-125 HIPDM in the kidney, liver, heart and blood compared to control rats (P < 0.05). However, there was a significant decrease in the uptake of I-125 HIPDM in the spleen compared to control animals (P < 0.001). The lung and brain of CsA treated rats showed no change in the uptake of I-125 HIPDM when compared to control rats. The change in the uptake of I-125 HIPDM in these organs was assumed to indicate tissue response to the toxic effects of CsA. The radiopharmaceutical results were comparable with the histopathological findings in which the organs showed varying degrees of tissue degeneration. It is concluded that the lipophilic radiopharmaceutical, I-125 HIPDM, can be used as an effective screening agent to study multiorgan toxicity due to CsA.

Fine needle aspiration cytology diagnosis of male breast lesions. A study of 185 cases.

OBJECTIVE: To study the fine needle aspiration (FNA) cytologic features of male breast lesions and to determine the efficacy of FNA cytology in the diagnosis of these lesions. STUDY DESIGN: During a five-year period (July 1988-June 1993), 188 males with breast lesions were investigated by fine needle aspiration cytology (FNAC). Slides were available for review in 185 of these cases. RESULTS: Gynecomastia was the most common lesion (132 cases), followed by benign tumors and cysts (16 cases), carcinoma (6 cases) and inflammatory lesions (5 cases). In 26 cases the smears were considered inadequate. The cytologic features of gynecomastia included cohesive sheets of bland cells (100.0% of cases), bipolar bare nuclei (76.5%) and columnar cells (38.6%). Mild nuclear atypia was observed in seven cases. The cytologic features consisted of dyshesive groups of ductular cells with moderate to severe nuclear atypia and absence of bare nuclei as well as columnar cells. The benign tumors and cysts included lipomatous lesions (10 cases), spindle cell tumors (3 cases) and epidermal inclusion/pilar cysts (3 cases). Histology was done in 25 cases. Diagnostic accuracy of FNAC for gynecomastia, benign tumors and malignancy was 100.0%, 100.0% and 66.7%, respectively. The only discrepant case was a carcinoma, diagnosed as highly suspicious on the cytologic specimen.

Autopsy survey for Alzheimer's disease in Nigerian Africans: a preliminary report.

We carried out an autopsy survey on 198 brains of Nigerians aged 40 years and above to determine the occurrence of (neuropathognomonic) changes of Alzheimer's disease (AD) in our elderly patients. Forty five patients (23%) were above 65 years of age. Appropriately stained histological sections of various parts of the brains showed mild cortical neuronal loss and absence of neurofibrillary tangles, senile plaques and amyloid angiopathy--hallmarks of Alzheimer's disease and ageing reported in the Caucasians and Japanese.

Metaplastic carcinoma of the breast in a renal transplant recipient. Initial diagnosis by fine needle aspiration cytology and immunocytochemistry.

A 46-year-old woman presented with a mass in the left breast and left axillary lymphadenopathy. Five years earlier she had received a renal transplant from an unrelated donor because of end-stage renal failure secondary to adult polycystic kidney disease. She was on immunosuppression therapy in the form of cyclosporine, azathioprine and prednisolone. Fine needle aspiration cytology of the breast mass showed a metaplastic (sarcomatoid) carcinoma, whereas the axillary lymph node aspirate suggested carcinosarcoma. Immunocytochemical studies revealed dense positivity for vimentin in the sarcomatous component and positivity for epithelial membrane antigen in the epithelial component. Rare cells were positive for cytokeratin. The cytodiagnosis was confirmed by excision biopsy of axillary lymph nodes. The patient died on the fourth postoperative day following left mastectomy and axillary clearance. The histopathology report of the breast tumor showed sarcomatoid carcinoma.

Orbital histoplasmosis due to Histoplasma capsulatum var. duboisii: successful treatment with Septrin.

Four children with orbital histoplasmosis caused by Histoplasma capsulatum var. duboisii (one of whom had been unsuccessfully treated with amphotericin-B) were treated with a combination of trimethoprim and sulphamethoxazole (Septrin) and surgical drainage. All patients improved markedly during therapy with resolution of the lesions, and with no recurrence of infection in three patients, 1 year later. The fourth patient was lost to follow-up. Treatment was devoid of side effects. These findings clearly indicate that Septrin could be a safe alternative to amphotericin-B for the treatment of African histoplasmosis, especially in patients presenting with solitary or localized lesions.

HLA-DR associations in black type I diabetics in Nigeria. Further support for models of inheritance.

The distributions of HLA-A, -B, -(Bw4/Bw6), -C, -DR, -(DRw52/DRw53), and -DQ genes in 19 type I diabetics, 37 type II diabetics, and 13 nondiabetics of the Yoruba tribe in southwestern Nigeria were studied. Because no associations between type II diabetes and HLA were detected in the current study and such associations are not known to exist in most ethnoracial groups, type II diabetics plus nondiabetics were used as a group of controls for the group of type I diabetics. Trends toward associations between increased DR3 (53 versus 30% of controls) and decreased DR2 (21 versus 46% of controls) and type I diabetes were found (0.1 greater than P greater than 0.05). The strongest HLA association with type I diabetes in Caucasians is usually with DR4. The percent of DR4-positive type I diabetes (11%) was not significantly greater that that in the controls (4%). Because the strong HLA associations with type I diabetes in American Blacks are the same as in Caucasians (i.e., increased DR3 and DR4 and decreased DR2), the genetic contribution (i.e., the lack of an association with DR4) to susceptibility to type I diabetes in most Nigerian Blacks may be different from that in most Caucasians and American Blacks. Onset of diabetes in most of the type I subjects was after age 20, and type I diabetics were difficult to recruit for the study, in keeping with reports on the rarity of type I diabetes among Blacks in western Africa and reports of DR4, but not DR3, being correlated with an early age of onset in Caucasians.(ABSTRACT TRUNCATED AT 250 WORDS)