Sinonasal intestinal-type adenocarcinoma: immunohistochemical profile and comparison with colonic adenocarcinoma.

Sinonasal intestinal-type adenocarcinomas (ITAC), as their name implies, bear a striking resemblance to primary intestinal neoplasia. The value and limitations of immunohistochemistry in making this distinction have not been previously defined. We determined the immunohistochemical staining profile of 12 sinonasal ITAC and compared their staining with that of 12 histologically similar colonic adenocarcinomas. All ITAC stained for cytokeratin and epithelial membrane antigen. Additional positive reactions were as follows: B72.3, 11 of 12; Ber EP4, 11 of 12; Leu M1, 8 of 12; HMFG-2, 12 of 12; and BRST-1, weak staining in seven of 12 cases. All 12 ITAC were negative for vimentin, synaptophysin, and actin. Colonic carcinomas stained similarly for these markers. Three additional antigens differed in their expression in ITAC versus colonic tumors. Carcinoembryonic antigen was strongly present in only two of 12 ITAC, with focal positivity in six of 12 and no staining in four of 12 cases. In contrast, all 12 colonic adenocarcinomas were strongly positive for carcinoembryonic antigen. Chromogranin-positive cells were present and often numerous in nine of 12 ITAC, in contrast to only rare positive cells in three of 12 colonic tumors. Neuron-specific enolase was present in five of 12 ITAC but was absent from all colonic tumors studied. ITAC are less often and less strongly carcinoembryonic-antigen positive and more prone to exhibit divergent neuroendocrine differentiation. These features may be of some value in distinguishing ITAC and colonic metastases. Neuroendocrine differentiation in ITAC was associated with higher mortality. Of the five patients with ITAC having 1+ to 2+ chromogranin positivity, only one was free of disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Bladder outlet obstruction after multiple periurethral polytetrafluoroethylene injections.

Periurethral polytetrafluoroethylene (Teflon) injections have been reported to be successful for the treatment of urinary incontinence after transurethral resection or radical prostatectomy. However, the use of polytetrafluoroethylene is controversial due to reports of distant migration and granulomatous reaction after periurethral injection. We report on a patient with a history of periurethral polytetrafluoroethylene injection for postoperative stress incontinence in whom bladder outlet obstruction developed and who underwent repeat transurethral resection 9 years later. Pathological examination revealed that the material responsible for the obstruction was almost totally composed of a foreign body giant cell response to the polytetrafluoroethylene implant ("teflonoma").

Papillomas of the breast. A histologic spectrum including atypical hyperplasia and carcinoma in situ.

We have illustrated intraductal papillomas that have a variety of alterations not found in "ordinary" or typical papillomas. Many of these changes are indistinguishable from ductal carcinoma in situ. A priori, one might expect that patients with papillomas associated with changes identical to ductal carcinoma in situ would be at an increased risk for subsequent invasive carcinoma. We suspect that there is an increased risk based on the fact that seven of our 26 cases (27 percent) had fully diagnostic ductal carcinoma in situ or invasive carcinoma in the breast. However, the degree of increased risk has not been definitely established.

RARA and PML gene rearrangements in acute promyelocytic leukemia with complex translocations and atypical features.

The translocation t(15;17) associated with acute promyelocytic leukemia (APL) results in fusion of the retinoic acid receptor alpha (RARA) gene on chromosome 17 with the putative transcription factor gene, PML, on chromosome 15. We report three cases of APL with complex cytogenetic translocations and five cases with atypical phenotypic features with rearrangements within or adjacent to the second intron of the RARA gene. Two patients demonstrated three-way translocations involving chromosomes 3, 15, and 17, but with differing breakpoints on the short arm of chromosome 3. A third patient developed a complex karyotype at the time of third relapse, but with no change in RARA and PML gene rearrangement pattern. Three patients had normal karyotypes; however, only small numbers of cells could be analyzed. One patient's leukemic cells expressed the T-cell-associated antigen CD2 and revealed T-cell receptor beta and gamma gene rearrangements. The localization of breakpoints to the second intron of the RARA gene in cytogenetically and phenotypically atypical cases provides additional support for a requisite role of the PML/RARA fusion gene in the pathogenesis of APL.

Serum amylase isoenzymes in ectopic pregnancy.

In general, significant amylase elevation was not documented in women with tubal pregnancies, compared with normal IUPs in the first trimester and a nonpregnant control range. One of 49 samples in 25 patients with tubal pregnancy was mildly elevated for salivary amylase.

Asymmetric radiographic findings in the pediatric chest: approach to early diagnosis.

Several conditions in children produce a mass effect within one hemithorax, which may be life threatening. The different radiographic appearances of these conditions provide a basis on which they can be classified. The three major categories include a large cystic hemithorax, a large lucent hemithorax, and a large opaque hemithorax. Some disorders may be seen within more than one major group. Within the large cystic hemithorax group, congenital cystic adenomatoid malformation and congenital diaphragmatic hernia may be life-threatening conditions that require emergency surgery. The large lucent hemithorax is usually caused by pneumothorax, partial bronchial occlusion, or compensatory hyperinflation of the unobstructed lung. The majority of cases within the large opaque hemithorax group involve pleural fluid collections. Because many conditions that cause a mass effect require intervention or surgery, accurate interpretation of the plain chest radiograph is essential for an early diagnosis. Classification of radiographic features into these three groups often allows accurate diagnosis without additional studies.

Intraarticular synovial sarcoma.

A 43-year-old man presented with decreased range of motion in his left knee and a painful medial joint mass that was grossly visible. Arthroscopy demonstrated a mobile, flat mass 3 cm in diameter in the knee joint that seemed to be loosely tethered to the synovium. The mass was excised, and light microscopic examination demonstrated a biphasic synovial sarcoma. There was no transition with the attached normal synovium. Immunohistochemically, the epithelial component was intensely positive for epithelial membrane antigen and cytokeratins (CAM 5.2 and AE 1/AE 3), and the spindle cell component was focally positive for these markers. The patient has no evidence of disease 9 years after only local excision. Although the term synovial sarcoma suggests a relationship to normal synovium, only rarely has truly intraarticular disease been reported.

Ovarian masses revisited: radiologic and pathologic correlation.

Diagnosis of ovarian masses can be difficult because many pathologic conditions can affect the ovary and have similar clinical and radiologic manifestations. Knowledge of pathologic, age-specific characteristics can help refine the differential diagnosis. Ovarian masses are nonneoplastic (ovarian functional cysts, polycystic ovary disease, and ovarian torsion) or neoplastic (surface epithelial, sex cord-stromal, germ cell, and metastatic tumors). Functional cysts, if complicated by hemorrhage, can have a confusing ultrasonographic (US) appearance. Polycystic disease and torsion are easily diagnosed with US. Benign and malignant forms of serous and mucinous surface epithelial tumors can usually be differentiated with US. Imaging features of surface epithelial tumors of low malignant potential are nonspecific, resembling those of benign serous and mucinous tumors. Mature (benign) teratomas are usually cystic, with components of fat, soft tissue, and calcium, and are sonographically distinct from immature (malignant) teratomas, which are mostly solid. Sex cord-stromal tumors occur more often in menopausal or postmenopausal women and are typically solid. Metastatic disease is less common than other ovarian tumors; however, its radiologic appearance may resemble those of other masses.

Benzocaine-adultered street cocaine in association with methemoglobinemia.

A 27-year-old man with a history of cocaine abuse ingested a large quantity of street cocaine in an apparent suicide attempt. Shortly thereafter, he developed tonic-clonic seizures and became cyanotic. An arterial blood gas sample, collected in the emergency department, appeared chocolate-brown and showed pO2 279 mmHg, pCO2 53 mmHg, and pH 7.15. Hemoglobin spectral analysis revealed significant methemoglobinemia (37%). Subsequent gas-chromatographic and mass-spectral analysis of urine confirmed the presence of cocaine (106 mg/L), benzoylecgonine (94 mg/L), and other metabolites. Further testing revealed the presence of benzocaine, a compound known to produce methemoglobinemia. A powder submitted as the "cutting" substance was shown to be benzocaine. When confronted with a possible cocaine overdose (particularly by ingestion), the physician should consider the possible clinical effects of adulterants, especially local anesthetics such as benzocaine.

Pathologic findings in nonpalpable invasive breast cancer.

Previous studies have shown that patients with nonpalpable invasive breast cancer have a favorable prognosis. These studies, however, have not analyzed pathologic features of mammographically detected tumors according to tumor size. We describe the histopathologic features of 77 nonpalpable invasive breast cancers, comparing neoplasms less than or equal to 1 cm with larger clinically occult tumors. Forty-seven lesions (61%) were less than or equal to 1 cm (group A) and 30 (39%) were greater than 1 cm (group B). In group A, there were 30 infiltrating ductal carcinomas (IDC); seven infiltrating lobular carcinomas (ILC); and two cases each of mixed ILC and IDC, mixed tubular carcinoma and ILC, and infiltrating cribriform carcinoma. There was one case each of mucinous carcinoma, apocrine carcinoma, tubular carcinoma, and mixed mucinous and IDC. In group B, there were 23 (77%) IDC, five (17%) ILC, and two mixed IDC and ILC. Tumors in group B were more frequently grade 3 (22% versus 7%), but this was not statistically significant (p = 0.21). There were no important differences in the frequency, subtypes and location of carcinoma in situ, or other histopathologic parameters evaluated in the biopsy specimens. Mastectomy specimens with axillary lymph node dissections were available for review in 64 cases (83%). Group B patients had a higher rate of residual invasive carcinoma (31% versus 13%) and lymph node metastases (31% versus 16%), but these differences were not statistically significant. Residual carcinoma in situ was more frequent in group B (54%) compared with group A (26%) (p = .036). Of seven group B cases with negative biopsy margins, residual invasive carcinoma was present in five (71%). We conclude that small nonpalpable invasive breast cancers differ from larger nonpalpable tumors primarily in size. The finding of negative biopsy margins should not be construed as conclusive evidence for the absence of residual infiltrating disease.

Accidental deaths involving derringer handguns: a report of three cases.

Accidental deaths due to discharge of dropped handguns have been previously reported. In this report, the authors review the history and design of the derringer handgun and describe three cases of accidental death due to discharge of derringer-type handguns. In two of these cases, the gun was dropped, resulting in a fatal discharge. The design of the derringer and the absence of a safety feature are cited as underlying factors. If the alleged weapon can be obtained, testing may demonstrate that discharge could occur if the gun were dropped.