Mortality after colon surgery: the value of a mortality registration system.

BACKGROUND/AIMS: Postoperative mortality after colon surgery is relatively infrequent. In order to evaluate the quality of colon surgery, post-mortem evaluation is useful. This study was performed to determine the value of a mortality register used at the Department of Surgery of the Red Cross Hospital. METHODS: From 1991 to 2000, 882 colon resections were performed for both malignant and benign disorders, including elective and emergency surgery. Permission for autopsy was asked routinely. All cases were reviewed and categorized in a multidisciplinary meeting. Any discrepancy between the clinical and post-mortem diagnosis was determined by a pathologist. RESULTS: The mortality rate of colon surgery was 8.0% (n = 71), 23% for emergency surgery and 6% for elective surgery (p < 0.001). For patients under 70 years of age the mortality rate was 4.3%, for patients over 70 years of age 11.2% (p < 0.001). Autopsy was performed in 62% (n = 44) of the patients. Discrepancy between clinical and post-mortem findings was documented in 14%. CONCLUSION: Postoperative mortality after colon surgery is influenced by the timing of surgery (elective or emergency procedure) and the age of the patient. A discrepancy of 14% between clinical cause of death and post-mortem cause of death justifies the need for obtaining autopsy in this type of surgery.

Nature's high-voltage injuries: sometimes a deadly consequence.

A patient is described who presented with the clinical picture of respiratory failure, persistent comatose state and myocardial injury after being struck by lightning. The discussion reviews the management of lightning injuries with emphasis on cardiovascular and neurological complications.

A series of carcinoid tumours of the breast.

Eight patients with a carcinoid tumour of the breast were treated between 1985 and 1992. All were reviewed for their history, physical examination, mammographic and ultrasound features. Staining methods according to Grimelius, with H&E and Neurone Specific Enolase were repeated, and all were positive. In only one patient was a positive axillary lymph node found. No recurrences were seen during follow-up. In agreement with the available literature there seems to be a less aggressive behaviour of carcinoid tumours of the breast in patients over 65 years of age. When a carcinoid tumour is suspected in this age group, the diagnosis can be confirmed by (immuno)histological analysis of a needle biopsy. If the diagnosis of carcinoid is confirmed, a limited operation, without an axillary lymph node dissection, may be considered.

Four cycles of BEP versus an alternating regime of PVB and BEP in patients with poor-prognosis metastatic testicular non-seminoma; a randomised study of the EORTC Genitourinary Tract Cancer Cooperative Group.

We have investigated whether an alternating induction chemotherapy regimen of PVB/BEP is superior to BEP in patients with poor-prognosis testicular non-seminoma. A total of 234 eligible patients were randomised to receive an alternating schedule of PVB/BEP for a total of four cycles or four cycles of BEP. Poor prognosis was defined as any of the following: lymph node metastases larger than 5 cm, lung metastases more than four in number or larger than 2 cm, haematogenic spread outside the lungs, such as in liver and bone, human chorionic gonadotrophin > 10,000 IU l-1 or alphafetoprotein > 1000 IU l-1. The complete response (CR) rates to PVB/BEP and BEP were similar, 76% and 72% respectively (P = 0.58). In addition, there was no significant difference in relapse rate, disease-free and overall survival at an average follow-up of 6 years. The 5-year progression-free and survival rates in both treatment groups were approximately 80%. The PVB/BEP regime was more toxic with regard to bone marrow function; the frequencies of leucocytes below 1000 microliters-1, leucocytopenic fever and platelets below 25,000 microliters-1, throughout four cycles were 28% vs 5% (P < 0.001), 16% vs 5% (P = 0.006), and 10% vs 1% (P = 0.001) respectively. Neuropathy also occurred more often in the PVB/BEP arm: 47% vs 25% (P = 0.001). This study shows that an alternating regimen of PVB/BEP is not superior to BEP and that it is more myelo- and neurotoxic.

Sweet syndrome associated with liposarcoma: a case report.

A 36-year-old woman with a dedifferentiated liposarcoma is described who had suffered from Sweet syndrome in the past. From the literature a relationship between this syndrome and malignancy is known to exist. However, the combination of Sweet syndrome with a sarcoma has not previously been reported.

Biopsy specimen identification by detection of sex chromosomes: application of in situ hybridisation.

AIMS: To investigate the feasibility of non-radioactive in situ hybridisation (ISH) for the identification of sex-mismatched plastic embedded bone marrow biopsy specimens. METHODS: After a suspected accidental transposition of two glycol-methacrylate embedded bone marrow specimens, in situ hybridisation with sex chromosome specific probes was performed. RESULTS: Quantitative analysis of the hybridisation signals established unequivocably the origin of the specimens. CONCLUSIONS: ISH is feasible on GMA embedded bone marrow specimens, and can be used for the identification of accidentally transposed specimens provided that they are of sex-matched origin.

Malignant lymphoma of the gastrointestinal tract and mesentery. A clinico-pathologic study of the significance of histologic classification. NHL Study Group of the Comprehensive Cancer Center West.

A series of 92 malignant lymphomas of the gastrointestinal tract and mesentery obtained from a population-based registry was studied to assess whether the newly defined concept of mucosa-associated lymphoma has clinical relevance. The cases were grouped according to localization; gastric, intestinal, and mesenteric lymphoma. All cases were reviewed histologically, graded according to the Working Formulation, and reclassified according to the Kiel classification, which was modified to include the categories low- and high-grade mucosa-associated lymphoma. Clinical data, as well as staging and follow-up data, were related to both the original diagnosis and the diagnosis after reclassification. The results showed that the distribution of the types of lymphoma is related to site: centroblastic lymphoma was predominant in the stomach, lymphoblastic in the bowel, and follicular centroblastic-centrocytic in the mesentery. Gastrointestinal lymphoma was disseminated in approximately 50% of the patients at presentation. Survival analysis revealed that classification according to the original Kiel classification and grading according to the Working Formulation provided important prognostic information, whereas introduction of mucosa-associated lymphoma as an entity did not. It was concluded that modification of current classifications to include a separate category for mucosa-associated lymphoma is not useful.

Angiotropic large cell lymphoma presenting as interstitial lung disease.

A case of angiotropic large cell lymphoma is reported in which the patient presented with only pulmonary symptoms. It suggests that this rare and highly malignant lymphoma should be considered in the differential diagnosis of interstitial lung disease, and shows the value of open lung biopsy in unexplained interstitial lung disease. This patient responded well to treatment with cyclophosphamide, doxorubicin, vincristine, and prednisone.

Leucostasis, an underestimated cause of death in leukaemia.

Massive sludging of leukaemic cells in blood vessels is a frequent and often lethal complication of leukaemia. In a retrospective clinicopathological study on the causes of death in 52 patients with acute myeloid leukaemia and myeloproliferative disease, pulmonary leucostasis was found in 40% of the patients. In many of these patients the vessels of the heart, brain and testes were also involved. In search for signs and symptoms specific for leucostasis, the clinical records of the 21 patients with leucostasis (the study group) were compared to those of 20 patients without leucostasis (the control group). Dysfunction of the organs most affected by leucostasis, namely lungs, heart and brain, was found more often in the study group than in the controls, but the combination of unexplained fever with cardiopulmonary and/or central nervous system failure occurred almost exclusively and in half of the patients with leucostasis. Leucostasis occurs predominantly, but not exclusively, in patients with high leucocyte counts, and especially, but again not exclusively, when the leucocyte counts rise sharply.

Immunohistochemical studies of the spleen in hairy-cell leukemia.

Immunohistochemical studies of 10 spleens from patients with hairy-cell leukemia (HCL) with a battery of monoclonal and heterologous antibodies were performed in order to obtain information on the phenotype of the neoplastic cells and the admixture of reactive cells. The hairy cells (HCs) were shown to react with several anti-B-cell antibodies (Y29/55, Leu10, HLA-DR), but only a minority of cases showed reactivity with antibody BA-1. The cells of all cases were nonreactive with anti-T and/or anti-macrophage antibodies. In contrast with cell-suspension studies, in immunohistochemical studies the HCs did not react with antibody OKM1. The reactive T-lymphocytes showed a shift toward T helper cells in the red pulp, but not in the white pulp. It was confirmed that "pseudosinuses" and "bloodlakes" are outlined by HCs and not by sinus-lining cells: the lining cells of the blood lakes were Y29/55+ and Leu10+, but negative with antibodies known to react with sinus-lining cells (Leu2a, BA-2). These data suggest that immunohistologic studies of the spleen in patients with HCL can be helpful in differential diagnosis and can provide information concerning the reaction of splenic tissue to the infiltration by hairy cells.

Histiocytic sarcoma (true histiocytic lymphoma): a clinicopathological study of 20 cases.

Large-cell non-Hodgkin's lymphomas (T- and B-immunoblastic, centroblastic and true histiocytic lymphomas) have a heterogeneous clinical course. In the present study the clinical and morphological data of 20 cases of histiocytic sarcoma (true histiocytic lymphoma) are presented. Diagnosis was supported by immunohistochemistry, cytochemistry, rosette assays and/or electron microscopy. Although the follow-up was relatively short (up to 144 months, mean 26 months), the clinical data differed clearly from the series of large-cell non-Hodgkin lymphomas, recorded in the literature. Differences were found in age distribution with a peak in the third decade, in organ involvement showing a preference for skin, gastrointestinal tract and bone, and in response to therapy. In general, histiocytic sarcoma appears to have a more favourable response to therapy and clinical course than the other large-cell lymphomas (T- and B-immunoblastic and centroblastic lymphomas). Moreover, preliminary observations in the group of histiocytic sarcomas suggested that the presence of lysozyme and/or 5-nucleotidase and the absence of alpha 1-antitrypsin in the cytoplasm is associated with a better response to therapy and favourable clinical course.

Unusual metastatic pattern in testicular malignant teratoma.

A 25-year-old man presented with a malignant teratoma of the right testicle. After orchidectomy, the results of the surgical staging procedure were negative. Although pulmonary metastasis did not occur, massive bone marrow involvement with a bleeding tendency and hypercalcemic nephropathy developed. The response to chemotherapy was excellent, but after the attainment of a complete remission the patient developed carcinomatous leptomeningitis, which was confirmed at autopsy as cause of death.

Busulphan aplasia in rabbits: a model for human aplastic anaemia.

Bone marrow histology plays a crucial role in the clinical diagnosis of aplastic anaemia. The nature of the disease means that few studies are available on the histological changes which occur in the early stages of the development of aplasia. We describe here an animal model which may have some relevance in this respect. Rabbits were chronically exposed to busulphan (BU) to induce aplasia. Sequential histological monitoring of the bone marrow was performed to obtain information about the events preceding full-blown aplasia. There was an early decrease and ultimate disappearance of granulo- and megakaryopoiesis with relative sparing of erythropoiesis which showed severe displasia. Increasing lymphoplasmacytoid infiltrate resembling that seen in human aplasia could be observed in the majority of the animals, together with a decrease of the peripheral lymphocyte number. Lymph nodes and spleen did not show lymphocyte depletion and serum gamma-globulin remained stable. Fibrosis was observed in 50% which is in contrast with human aplasia at diagnosis. In half of the animals there was a rise in MCV, which was not correlated with reticulocytosis or degree of dyserythropoiesis. BU-induced aplasia in rabbits, which resembles long-standing grade II human aplasia in many respects, might be a suitable model for the study of aplastic anaemia due to stem cell defects.

Morphometric characterization of diffuse large-cell (histiocytic) lymphomas.

From 28 large-cell lymphomas, defined by marker studies, enzyme histochemistry, and electron microscopy as large noncleaved follicle center cell tumors (lnc FCC), B-immunoblastic or true histiocytic lymphomas, morphometric cell parameters, including nuclear size and shape, cytoplasmic area, and cytoplasm-to-nucleus ratio, were measured. Moreover, size, number, and location of nucleoli in the nuclei of the characteristic cells of lnc FCC and B-immunoblastic lymphoma were determined. Statistical evaluation of the data showed the nuclear shape to be the most sensitive parameter in the differentiation of true histiocytic lymphoma from lnc FCC and B-immunoblastic lymphomas. With nucleolar parameters lnc FCC could be differentiated from B-immunoblastic lymphoma: lnc FCC had a higher mean number of nucleoli per cross-section of nucleus and more eccentrically located nucleoli. Moreover, the measurements show that the differences in number and location of nucleoli between large noncleaved follicle center cells and B-immunoblasts are smaller than generally described in the literature. Our results show that it is possible to differentiate by morphometry between lnc FCC, B-immunoblastic, and true histiocytic lymphomas.

The implications of subjective recognition of malignant cells in aspirations for the grading of prostatic cancer using cell image analysis.

A pilot study of selective morphometry was performed in smear preparations from fine needle aspirates of six cytologically graded prostatic carcinomas. Given the instruction to select carcinoma cells with large nuclei for measurement, cytotechnologists and a cytopathologist differed in the selection of cells from grade III tumors. The cytotechnologists had discarded large bare atypical nuclei because they assumed that these were degenerated cells. Transmission electron microscopy, using an open-face embedding technique, demonstrated, however, that these cells were not degenerated but were poorly differentiated carcinoma cells that had lost their cytoplasm during smear preparation. It is obviously of great importance for the morphometric discrimination of grade I and grade III carcinomas that such bare atypical nuclei be included in the selections of cells to be measured. Our data indicate that the measurement of 20 selected cells per smear preparation is sufficient for accurate morphometric grading and that such measurements are reproducible.

Dendritic reticulum cell sarcoma? Four cases of a lymphoma probably derived from dendritic reticulum cells of the follicular compartment.

This paper describes the histological picture of four tumours of the follicular compartment of the lymph node, in which the proliferating cell appeared to be the dendritic reticulum cell (DRC). This assumption was based on the results of light microscopical, ultrastructural, immunological, and enzymehistochemical investigations. The tumour cells resembled DRC's closely in (1) the striking pattern of interdigitations and occasional tight junction-like contacts between the neoplastic cells on electron microscopical analysis; (2) presence of receptors for the activated third component of complement on the membrane of the cells; (3) absence of monoclonal immunoglobulins and T-cell antigen on the surface and of lysozyme, alpha 1-antitrypsin or alpha 1-antichymotrypsin in the cytoplasm of the neoplastic cells. Moreover, (4) the tumour cells showed moderate alpha-naphtyl acetate esterase, weak to absent acid phosphatase and (with one exception) strong 5-nucleotidase activity. Furthermore, (5) the neoplastic cells expressed Ia-like antigens on the surface in all four cases. The relation with follicle centre cell lymphomas, the differential diagnosis and clinical data are discussed.