Primitive neuroectodermal tumor of the myocardium: a case report, review of the literature, immunohistochemical, and ultrastructural study.

We report the case of a primitive neuroectodermal tumor (PNET) arising in the heart of a 63-year-old man. The neuroectodermal nature of this tumor was confirmed by the immunohistochemical positivity for O13 (CD99) (the P30/32MIC2 gene product) neuron specific enolase (monoclonal and polyclonal), synaptophysin and vimentin. Other markers, such as actin, desmin, myoglobin, chromogranin, keratin, and leukocyte common antigen were negative. The diagnosis was made on an endomyocardial biopsy and was confirmed in sections from the myocardial tumor found within the heart excised during cardiac transplant. Primitive neuroectodermal tumors have been reported in a variety of sites, most commonly in the extremities. No case has ever been reported within the myocardium, although one has been reported in the pericardium. In addition to morphological similarities, PNET and extraskeletal Ewing's sarcoma have been shown to possess the same chromosomal translocation, t11;22, and the same cell surface antigen, P 30/32. Separation of this case from extraskeletal Ewing's sarcoma was possible because of the absence of PAS positivity, as well as the immunohistochemical positivity for at least two neural markers, as extraskeletal Ewing's sarcoma is only positive for neuron specific enolase.

Cervical smears prepared by an automated device versus the conventional method. A comparative analysis.

An automated, fluid-based method for the preparation of cervical Papanicolaou smears/slides was compared to the conventional Papanicolaou smear (CPS) method used for the screening of neoplasia. We determined diagnostic agreement and sources of error for diagnostic disagreement. For 665 patients, one cervical sample was collected to make one CPS. The collection devices, a wooden Ayre spatula and endocervical brush, were rinsed into a vial with fluid medium to be processed in the automated device. All slides were distributed among five cytotechnologists in a blind fashion. Exact diagnostic agreement was 94.6%. The results were not statistically significant (P > or = .70, McNemar's test) but were clinically important, as evidenced by the detection of low grade lesions (LGL), during initial screening, on three slides prepared by the automated device but not on their matched-pair CPSs (0.5% of all specimens). After reevaluation, the three matched CPSs demonstrated LGL. Sources of diagnostic error on the CPSs were: air-drying artifact, obscuring blood/inflammation, crowding/overlapping of cells and/or absence of diagnostic cells. The only source of error in the automated-method smears was absence of diagnostic cells.

Automated Speech-recognition Anatomic Pathology (ASAP) reporting.

Artificial intelligence speech-recognizers integrated with Laboratory information and Telefaxcommunication Systems have allowed for totally automated surgical pathology reporting. Automated Speech-Recognition Anatomic Pathology (ASAP) reporting improves the speed, text accuracy, comprehensiveness, and workflow management of diagnostic reports while eliminating support personnel. Healthcare reform goals of increased productivity and economy are furthered. Reports are rendered "as soon as possible" (ASAP) expediting appropriate clinical management and decreased length of stay and hospital costs.

The number of CD1a+ large low-density cells with dendritic cell features is increased in the peripheral blood of HIV+ patients.

Employing a discontinuous Percoll gradient following Ficoll-Hypaque separation of peripheral blood mononuclear cells from normal subjects (n = 14) and patients with HIV-1 infection (n = 50), we separated a population of low-density cells consisting of monocytoid cells, lymphocytes, and some granulocytes. In cytospin preparations, less than 5% of the monocytoid cells were positive for nonspecific esterase and CD14. However, CD1a was positive in 5-20% of these cells. Ultrastructurally, CD1a-labeled immunogold particles were demonstrated on the monocytoid cells which bore some features of dendritic cells. Flow cytometry of the low-density cells identified a subset of buoyant, large cell population, which excluded lymphocytes. This large low-density cell (LLDC) population was significantly expanded in patients with HIV infection and comprised 32.3 +/- 21.3% of low-density cells compared to 7.0 +/- 2.8% in normal subjects (P < 0.0001). Of the LLDC population 45.2 +/- 23.4% were CD1a+ in patients compared to 17.5 +/- 13.3% in normal subjects (P < or = 0.0001). HLA-DR and HLA-DQ were coexpressed in approximately 70 and 50% of these CD1a+ LLDC, respectively. A simple nonculture assay method employed by us facilitates rapid screening of infected blood specimens for the CD1a+ large low-density cells with dendritic cell features, which could be an additional parameter to monitor HIV disease progression.

Expression of cell adhesion molecules associated with germinal center in Hodgkin's disease: an immunohistochemical study. The germinal center related complex and histologic subtypes.

BACKGROUND: Of the four elements known to be associated with germinal center formation--B-cells, follicular dendritic cells, T-cells, and the cell adhesion molecules--the first three have been well studied in Hodgkin's disease, especially the nodular lymphocytic predominance subtype, established as a tumor of germinal center origin. However, no study has been done on the expression of the cell adhesion molecules associated with germinal center formation in Hodgkin's disease. METHODS: Using the avidin-biodin peroxidase complex method, we studied the staining patterns for CD11a (lymphocyte function-associated antigen 1), CD54 (intercellular cell adhesion molecule 1), and very late antigen 4 (VLA-4) in frozen sections from 24 cases of Hodgkin's disease, along with those for follicular dendritic cell and cell surface markers for lymphocytes. RESULTS: Reed-Sternberg cells and their variants and histiocytic cells stained for CD54. Lymphocytes stained for CD11a. Lymphocytes either formed patchy aggregates or dispersed without forming aggregates. Aggregating lymphocytes expressed CD20 (L-26), whereas dispersed, nonaggregating lymphocytes expressed CD3/CD4, or CD3/CD8. Extracellular matrices of these CD20+ B-cell aggregates stained for CD54, VLA-4, and follicular dendritic cells. CD54 staining revealed four patterns of reaction products deposits: discretely patchy, confluent, predominantly diffuse, and diffuse only. The discrete-patch predominance pattern was seen in the lymphocytic predominance type, both nodular (n = 3) and diffuse (n = 2), and in classic nodular sclerosis with broad collagen bands (n = 4). The confluent pattern was seen in tumors with features of cellular-phase nodular sclerosis versus mixed cellularity type (n = 3). The predominantly diffuse was observed in the remainder of nodular sclerosis type with infrequent, narrow collagen bands (n = 5), in cellular-phase nodular sclerosis (n = 1), in cellular-phase nodular sclerosis versus mixed cellularity type (n = 2), and in mixed cellularity (n = 2). The diffuse-only pattern occurred in mixed cellularity with abundant fibrohistiocytoid stromal cells (n = 2). CONCLUSIONS: The cell adhesion molecules associated with germinal center formation were expressed in the great majority of cases of Hodgkin's disease. The expression was closely associated with the occurrence of distinctive CD20+ B-cell aggregates and follicular dendritic cell networks, forming a germinal center-related complex, and the presence of the complex correlated with nodular sclerosing features.

Intercellular adhesion molecule-1 (ICAM-1) staining of reactive and neoplastic follicles. ICAM-1 expression of neoplastic follicle differs from that of reactive germinal center and is independent of follicular dendritic cells.

BACKGROUND: Intercellular adhesion molecule-1 (ICAM-1) is expressed on follicular dendritic cells (FDC), and the ICAM-1/LFA-1 pathway is essential for affinity selection of activated B-cells in germinal centers (GC). The expression of ICAM-1 has been studied by immunostaining methods in GC, but not in neoplastic follicles (NF). METHODS: The authors studied the expression of ICAM-1 by the avidin-biotin-peroxidase complex (ABC) method with frozen sections in GC of reactive nodes (n = 22) and NF of follicular lymphomas (n = 19), in comparison with FDC staining. RESULTS: GC stained uniformly for ICAM-1, with staining intensity varying little from node to node, and follicular borders were well demarcated from the surroundings. Endothelial cells within GC did not stain whereas those outside stained strongly. In contrast, NF stained variably from tumor to tumor, and in any given tumor. Characteristically, follicular borders were not demarcated, and stained areas were difficult to define due to the lack of demarcation, with the exception of large cell type with diffuse areas (n = 2). Endothelium of intrafollicular vessels stained prominently (12 of 19), and appeared to contribute to the staining intensity of the follicles. FDC staining revealed a meshwork pattern in GC which was similar to that of ICAM-1. The FDC mesh-work pattern was present in 15 tumors. The pattern was remarkably uniform with sharply defined borders, which contrasted starkly to the variable staining and lack of follicular borders in the ICAM-1 stain of the same tumors. CONCLUSIONS: The staining pattern of follicles for ICAM-1 was similar to that for FDC in reactive nodes, but distinct from the latter in follicular lymphomas. An appropriate expression of ICAM-1 appears to be essential for normal GC, as the alteration of the expression coincides with the malignant transformation of GC. The altered expression of ICAM-1 may be useful in distinguishing NF from reactive GC.

A comparative study of DNA ploidy in 115 fresh-frozen breast carcinomas by image analysis versus flow cytometry.

BACKGROUND: Qualitative and quantitative analysis of cellular DNA content may be clinically useful in the prognostic evaluation of certain types of malignant tumors, including breast carcinoma. Flow cytometric (FCM) analysis has been the most frequently used procedure for DNA analysis, but it requires a reasonably large tissue sample. Computer-based image analysis (IA) now allows imprint, cytospin, and needle aspiration smear preparations and other small tissue samples to be used. METHODS: To resolve concern about the diagnostic efficacy of small tissue samples in the use of IA, the authors performed a comparative study of FCM analysis and IA using 115 fresh-frozen breast carcinomas. Feulgen-stained imprint preparations for IA and single-cell suspensions from the same fresh-frozen tissue for FCM analysis were used, and the respective histograms were compared. RESULTS: The results were concordant in 90.4% (104 of 115) of the cases, but 11 specimens yielded discordant data. IA provided histograms with a somewhat lower resolution and a relatively high coefficient of variation for the G0/G1 peak, thus rendering occasional tumors, which were near-diploid aneuploid by FCM analysis (four cases), not amenable to diagnosis by aneuploid characterization. In three additional cases, FCM analysis showed aneuploid hyperdiploid (two cases) and multiploid (one case) histograms, but IA only demonstrated a diploid peak. Conversely, in four other cases, aneuploid peaks were recognized only by IA. CONCLUSIONS: Computerized IA has significant advantages over FCM analysis, including lower cost, the ability to analyze very small specimens, the capability of detecting rare high ploidy cells, the capacity to classify cellular populations according to specific morphologic type, and the fact that no destructive enzyme or chemical digestion is required for specimen preparation, thereby preserving the integrity of fragile cells.

The Lewis X antigen. A new paraffin section marker for Reed-Sternberg cells.

Using a monoclonal antibody specific to the Lewis X antigen (anti-Lex), the authors studied 103 cases of Hodgkin's disease (HD) in comparison with 57 cases of non-Hodgkin's lymphoma (NHL); three cases of granulocytic sarcoma (GS); two cases of malignant histiocytosis (MH); one case of monoblastic leukemia (ML); one case of interdigitating reticulum cell sarcoma (IRCS); six cases of histiocytosis X (HX); one case of reticulohistiocytoma (RH); 44 various reactive conditions of the lymph node (LN). Reed-Sternberg and related (R-S) cells stained selectively in 80 of 92 cases of HD (87.0%), excluding 11 cases of lymphocyte predominance type. The stain was better in B-5-fixed specimens than in formalin-fixed specimens, showing a dense deposit of reaction products at a paranuclear site and on the cell surface. The staining results were compared with those of Leu-M1 and found to be superior both qualitatively and quantitatively (detection rate of R-S cells: 87.0% versus 68.5% of Leu-M1). Granulocytes, rare epithelioid histiocytes, and some endothelial and/or erythrocytes also stained with anti-Lex. The stain had positive results in three cases of GS showing a diffuse cytoplasmic staining pattern. Of NHL, two of 29 peripheral T-cell lymphomas stained to show rare paranuclear deposits without cell surface staining. The stain had negative results in MH, ML, IRCS, HX, and RH. Of 45 reactive LN, minute subcapsular collections of Lewis X+, altered-appearing Langerhans'-like cells, were observed in all ten LN from human immunodeficiency virus (HIV)-associated persistent generalized lymphadenopathy (PGL). The stain had negative results in all other various reactive conditions of LN. In conclusion, Lewis X staining is useful as a marker for R-S cells in paraffin sections with staining results superior to those of Leu-M1. Lewis X staining also detects subcapsular clustering of altered-appearing Langerhans'-like cells in PGL, which has not been described previously and warrants additional study.

Individual human tumors in short-term micro-organ cultures: chemosensitivity testing by fluorescent cytoprinting.

Using innovative approaches, we addressed several problems often associated with in vitro chemosensitivity testing of individual human tumors: 1) obtaining a high rate of evaluability; 2) excluding participation of nonmalignant stromal and vascular components usually present in tumor specimens; 3) preserving cell-to-cell interactions present in the original tumor; 4) assessing drug-induced cytotoxicity without sacrificing the tumor culture. To circumvent these problems, tumor specimens were processed as follows: i) tissue (fresh or cryopreserved) was mechanically or enzymatically dissociated under mild conditions into cellular clusters (termed micro-organs); ii) large micro-organs were separated by a brief decantation, resuspended, and then exposed to fluorescein acetate to visualize (under naked eye) viable micro-organs; iii) fluorescent (i.e., viable) micro-organs were collected using a Pasteur pipette, and then planted on a solid support made of cellulose fibers impregnated with collagen. Since tumor micro-organs have been previously shown to consist solely of malignant cells, the procedure described here not only preserves a critical portion of the tumor architecture but eliminates at the onset necrotic tissue and nonmalignant cellular components that could interfere with the chemosensitivity testing. Drug-induced cytotoxicity was measured by "fluorescent cytoprinting", a novel, nondestructive procedure for assessing micro-organ viability in situ. The key feature of fluorescent cytoprinting is that cytotoxic effects are not measured against control cultures but against a baseline provided by a cytoprint of the same culture before drug addition. Using three experimental designs, we tested the potential of the method for clinical applications. The results using 469 human malignant tumors showed that the micro-organ culture assay can distinguish individual tumor chemosensitivity profiles with an overall success rate of 96%. For three commonly used chemotherapeutic drugs, the observed frequency of responding tumors was found to be comparable to previously reported clinical results using single agents.

Effects of antiplatelet drugs on pulmonary responses to thrombin in anesthetized rabbits.

Platelet aggregation and fibrin deposition in the pulmonary circulation may contribute to the pathogenesis of lung injury in the adult respiratory distress syndrome (ARDS). We evaluated the effect of two antiplatelet drugs (forskolin & dipyridamole) on pulmonary responses to intravenous infusion of 100 NIH units of thrombin per kg bw in anesthetized, and ventilated rabbits treated with fibrinolysis inhibitor. Thrombin infusion resulted in pulmonary hypertension and increased arterial CO2 tension (PaCO2) and dead space ventilation (VD/VT). Arterial oxygen tension (PaO2) and numbers of circulating leukocytes and platelets dropped after thrombin infusion. These early hemodynamic changes correlated with histological evidence of entrapped leukocytes in the pulmonary microcirculation and transient alveolar edema. Microthrombi were rarely observed in animals that received thrombin. There was little evidence for endothelial damage or progressive lung water accumulation. Treatment with forskolin or dipyridamole reversed thrombin-induced changes in pulmonary artery pressure, PaCO2, VD/VT and systemic oxygenation. Moreover, forskolin and dipyridamole blunted the drop in circulating leukocytes and prevented the development of alveolar edema following thrombin. The beneficial actions of these agents may be due to interference with the release of mediators from leukocytes or platelets.

Interaction of thromboxane A2 and tissue pathology during graded bacteremia.

The purpose of this study was to determine whether or not thromboxane A2 (TXA2) was necessary or sufficient for the development of end-organ pathology during graded bacteremia. Pulmonary artery catheters were placed in 21 adult male pigs under pentobarbital anesthesia and breathing room air. After a control period, animals were studied in four groups: Group 1, anesthesia only; Group 2, infusion of 1 X 10(9) ml Aeromonas hydrophila which was gradually increased from 0.2 ml/kg/hr to 4.0 ml/kg/hr over 4 hours; Group 3, pretreatment with SQ 29,548 (TXA2 antagonist) then Aeromonas h. infusion; Group 4, infusion of U46619 (TXA2 agonist) to pulmonary artery pressures measured in Group 2. Animals were sacrificed after 4 hours and the lungs, liver, spleen, kidneys, and heart were examined under light microscopy by a pathologist unaware of study groups. The results indicated that physiologic thromboxane A2 agonist (Group 4) was sufficient alone to cause pulmonary inflammation. Thromboxane A2 was neither necessary nor sufficient for significant renal, hepatic, pulmonary, or splenic pathology to occur in graded bacteremia, manifested in similar microanatomic abnormalities in these organs in Groups 2 and 3 and in Groups 1 and 4. Pulmonary leukocyte infiltration was significantly increased in Group 3 compared to all other groups, suggesting that TXA2 impairs inflammatory responses.

Nontraumatic fat embolization. A rare cause of new pulmonary infiltrates in an immunocompromised patient.

Diffuse pulmonary infiltrates and hypoxemia are common in immunocompromised patients. We describe a patient with lymphoma who developed hypoxemia and diffuse pulmonary infiltrates during treatment with corticosteroids. Open lung biopsy and postmortem examination indicated that the cause of the infiltrates was nontraumatic fat embolization (NTFE). Most previous cases of NTFE have implicated a fatty liver as the source of emboli; however, this patient had no fatty changes of the liver. The diagnosis of NTFE in an immunocompromised patient is difficult to make because its distinguishing features, such as hypoxemia, petechiae, and altered mental status, are nonspecific in this setting.

Consecutive repair of complex congenital heart disease using hypothermic cardioplegic arrest--its results and ultrastructural study of the myocardium.

Cold potassium cardioplegia was used in 78 consecutive patients undergoing correction of complex congenital heart disease between 1977 and 1982. Ages ranged from 4 weeks to 21 years (mean 6.7 years). The anatomical diagnoses were: tetralogy of Fallot (33), common AV canal (12), pulmonary atresia with ventricular septal defect (VSD) with previous shunts (5), transposition of great arteries (5), total anomalous pulmonary venous return (3), complex VSD (4), and complex anomalies (16). There were 3 deaths (4%). Electron microscopy was performed on biopsy specimens taken from the hypertrophied or volume-loaded cardiac chamber (1) before perfusion, (2) after cardioplegia, and (3) 30 minutes after cardioplegia. It showed near normal myocardial ultrastructure after cardioplegic arrest, however there was minimal mitochondrial and intracellular edema after reperfusion. Post-operatively, 80% of the patients had spontaneous defibrillation and only 10% required brief inotropic support. The operative exposure was excellent. No patient developed heart block during repair.

Lung function and structure after Escherichia coli endotoxin in rabbits: effect of dose and rate of administration.

We evaluated the effect of increasing doses of Escherichia coli endotoxin and its rate of administration on systemic blood pressure, alveolar-arterial oxygen gradient (A- aDO2 1.0), dynamic compliance (Cdyn), circulating platelets and leukocytes, and postmortem bloodless wet to dry ratios in anesthetized rabbits. Infusion of endotoxin resulted in systemic hypotension, diminished Cdyn, thrombocytopenia, and leukopenia, but did not influence venous admixture. These parameters were not affected by the rapidity of administration, but changes in Cdyn and circulating platelets were dose-dependent. High (15 mg/kg), but not low (0.5 mg/kg), doses of endotoxin resulted in an early but transient increase in lung water, but bloodless wet to dry weight ratios were not increased at 4-6 h following endotoxin even when high doses were injected. Ultrastructural studies done in six rabbits showed an early but transient platelet sequestration in pulmonary capillaries, progressive increase in intracapillary leukocytes, interstitial edema, and focal, although minimal, endothelial injury at 4 h after injection. Thus, infusion of E coli endotoxin in rabbits does not result in increased lung water and intrapulmonary shunting acutely; this tolerance to endotoxin is not related to the dose or rates of administration studied.

Parathyroid surgery: the role of chief cell intracellular fat staining with osmium carmine in the intraoperative management of patients with primary hyperparathyroidism.

The surgeon's gross evaluation, the hematoxylin and eosin stain, which assesses extracellular fat, and a new intracellular fat stain, osmium carmine, were comparatively evaluated in 30 consecutive patients who underwent surgery for primary hyperparathyroidism. The surgeon's gross judgment of enlarged and normal parathyroid tissue resulted in the correct functional assessment in 98% and 97% of the glands, respectively. The surgeon's functional assessment was correct in seven of 10 parathyroid glands that were considered by gross examination to be slightly enlarged (50 to 80 mg). The osmium carmine intracellular fat stain provided a correct functional assessment in all 10 of these glands. The osmium carmine stain also appears to have a role in providing scientific quantitative data to limit operations in patients who have a parathyroid adenoma to removal of the adenoma and biopsy of a grossly normal gland that demonstrates normal intracellular fat. Only one side of the neck was explored in 11 patients who fulfilled these criteria. There has been no persistent or recurrent hypercalcemia in these patients.

Electrolyte versus blood cardioplegia: randomized clinical and myocardial ultrastructural study.

In 40 consecutive patients undergoing coronary artery bypass, one of two solutions for cardioplegia, each containing 30 mEq/L of K+ was used randomly. The groups were comparable except for intramyocardial temperature. With electrolyte solution (Group A), it was 16.5 degrees +/- 0.34 degrees C, while with blood from the pump-oxygenator (Group B) it was 20.3 degrees +/- 0.41 degrees C (p less than 0.001). After bypass left atrial pressure (LAP) was 11.9 +/- 0.67 torr in Group A and 8.1 +/- 0.49 torr in Group B (p less than 0.001). CPK-MB was elevated in 45% of Group A patients versus 15% in Group B (p less than 0.05). No patient died. Two myocardial infarctions occurred in Group A and one in Group B. Stereological morphometric electron microscopy was performed on biopsy specimens taken from the left ventricle (1) before perfusion, (2) after cardioplegia, and (3) 30 minutes after reperfusion. Group A showed marked intracellular edema, mitochondrial swelling, pronounced depletion of glycogen stores, and focal myofibrillary disorganization. Group B showed near normal myocardial ultrastructure with increased glycogen stores and minimal mitochondrial swelling. Morphometric analysis revealed a statistically significant increase in the degree of mitochondrial swelling (51%) in Group A compared with Group B after reperfusion (p less than 0.001). Thus, blood K+ cardioplegia resulted in better preservation of myocardial ultrastructure, lower ventricular filling pressure, and lesser CPK-MB release compared with this particular electrolyte cardioplegia.