A. R. von Hochstetter

Optimization of prostate carcinoma staging: Comparison of imaging and clinical methods

Purpose: The diagnostic value of endorectal coil MRI, body coil MRI, transrectal ultrasound, digital rectal examination and PSA levels were prospectively analysed in order to define the most accurate preoperative staging method. Methods: 33 patients with prostate carcinoma, who underwent subsequent prostatectomy, were enrolled in the study and examined on a 1.5 T system using the body coil as well as the endorectal surface coil before and after the administration of contrast material. The results were compared to digital rectal examination, prostate specific antigen levels and endorectal ultrasound. Results: Staging accuracy of endorectal coil MRI was 87.9% with a sensitivity of 88.9% and specificity of 86.7%. For body coil MRI, the staging accuracy was 75.7%, the sensitivity 66.7% and the specificity 87.9%, for transrectal ultrasound 69.6%, 41.7% and 100% and for the digital rectal examination 56.6%, 33.3% and 100%, respectively. Prediction was improved by combining results of endorectal coil MRI with PSA values. Conclusion: Endorectal ultrasound and digital rectal examination both had a tendency to underestimate the extent of the lesion. Endorectal coil MRI proved to be the best preoperative staging method. In combination with PSA values, diagnostic accuracy could be further improved. Therefore, local staging of prostate cancer could be based on these two parameters alone.

Synovial sarcomas usually metastasize after >5 years: a multicenter retrospective analysis with minimum follow-up of 10 years for survivors

BACKGROUND Synovial sarcoma (SS) is a malignant soft tissue sarcoma with a poor prognosis because of late local recurrence and distant metastases. To our knowledge, no studies have minimum follow-up of 10 years that evaluate long-term outcomes for survivors. PATIENTS AND METHODS Data on 62 patients who had been treated for SS from 1968 to 1999 were studied retrospectively in a multicenter study. Mean follow-up of living patients was 17.2 years and of dead patients 7.7 years. RESULTS Mean age at diagnosis was 35.4 years (range 6-82 years). Overall survival was 38.7%. The 5-year survival was 74.2%; 10-year survival was 61.2%; and 15-year survival was 46.5%. Fifteen patients (24%) died of disease after 10 years of follow-up. Local recurrence occurred after a mean of 3.6 years (range 0.5-14.9 years) and metastases at a mean of 5.7 years (range 0.5-16.3 years). Only four patients were treated technically correctly with a planned biopsy followed by a wide resection or amputation. Factors associated with significantly worse prognosis included larger tumor size, metastases at the time of diagnosis, high-grade histology, trunk-related disease, and lack of wide resection as primary surgical treatment. CONCLUSIONS In SS, metastases develop late with high mortality. Patients with SS should be followed for >10 years.

Epithelioid sarcoma mimicking angiosarcoma: The value of immunohistochemistry in the differential diagnosis

Epithelioid sarcoma (ES) is a rare malignant tumour of young adults, usually presenting as a skin ulcer or subcutaneous nodule in the distal portion of the upper limb. Multiple recurrences and late metastases are typical, leading to fatality in a third to one-half of all cases. The slow evolution of the tumour is one reason for its delayed recognition. The other is its frequent histological misinterpretation, in particular, as a peculiar granulomatous reaction. In our case, the primary tumour presented a variant morphological pattern so closely mimicking a cavernous angiosarcoma as to mislead several reputable opinions. Later recurrences and metastases were typical of ES, while a focal angiomatoid pattern was maintained. The morphology and immunoreactivity to a wide spectrum of tumour markers is compared with that of six file cases of classical ES. Retrospectively, all neoplastic lesions in our patient were ES. In young adults, lesions of the upper extremity, even when angiomatoid or haemorrhagic, should raise a suspicion of ES. Once epithelioid sarcoma is suspected, the differential diagnosis can be elucidated on immunohistochemical grounds. Early diagnosis provides the best opportunity for radical surgery at a stage when the tumour has not spread locally or disseminated systemically.

The differential diagnosis of testicular germ cell tumors in theory and practice

To better appreciate the conflicts and controversy surrounding the classification of testicular tumors, and to reappraise their morphologic substrate under the advent of tumor markers, 389 of our own cases are reviewed, classified according to the systems advocated by the World Health Organization (WHO) and the Testicular Tumour Panel and Registry (TTPR) of Great Britain, and evaluated statistically. While many cases fit easily into either classification, the following difficulties were manifest: 1) Discrepancies in definitions and diagnostic criteria are the reason that considerably more germ cell tumors could be classified as mixed choriocarcinomas (WHO) than as trophoblastic teratomas (TTPR). It was found that tumor markers supply histochemical data that often conflict with rather than supplement morphologic ones in diagnosis and differential diagnosis. Similarly, the incidence of yolk sac structures, as yet not recorded separately by the TTPR, varies as either morphologic or histochemical criteria are applied. 2) The division of the morphologic spectrum of teratomatous differentiation by criteria of distinction that are unequal in the two systems yield comparable but non-congruent tumor entities. Consequently, borderline cases may undergo shifts to noncorresponding groups as they are translated from one system to the other. 3) Criteria separating teratoma with malignant transformation and polyembryoma (WHO) from closely allied lesions proved impractical. 4) Diagnostic labels that incorporate not only a morphologic pattern but a definite level in the histogenetic hierarchy generate a climate of incompatibility between systems whose histogenetic perspectives differ. Embryonal carcinomas claim to totipotence, in particular, leads to a conceptual split with the teratomas and brings the WHO system by itself into theoretic difficulties. Moreover, as the morphologic criteria for embryonal carcinoma are not in keeping with its histogenetic premise, the rigid separation is difficult to enforce in practice. Once the air is cleared, a resolution is easily reached. In the combined use of both classifications their real difference, splitting vs lumping, becomes a true asset.

The significance of giant cells in human testicular seminomas. A clinico-pathological study

In order to study the nature and significance of various giant cells encountered in seminomatous tumors of the testis, we reviewed the morphology of 243 consecutive pure seminomas and 107 combined (mixed) tumors, as well as the long term clinical follow-up in 26 patients. Giant cells were grouped into histocytic or neoplastic ones and the latter subtyped according to morphologic and immunocytochemical characteristics. Neoplastic giant cells were found in 34.6% of all pure seminomas and in 11.2% of all combined tumors, i.e. twice as often as histocytic giant cells in either tumor group. The various types of neoplastic giant cells were found alone or in combinations with other types. Giant cells capable of elaborating B-HCG were seen in 19.3 % of all pure seminomas and in 9.3% of seminomatous components of combined tumors. These incidences argue strongly against a trophoblastic element infiltrating a seminoma from a concomitant occult choriocarcinomatous focus. Large mononuclear giant cells, seen in spermatocytic seminomas, were observed in 15.6% of all pure seminomas, particularly in combination with B-HCG producing giant cells. Another type, characterized by marginated nuclei and eosinophilic cytoplasm were invariably part of a mononuclear cell population of similar features and encountered focally in 9.1% of all pure seminomas. Clinical follow-up, particularly in cases with B-HCG positive giant cells, revealed that treatment as for conventional seminomas at an early stage at least is followed by an excellent course.

Loose bodies in the temporomandibular joint: The advantages of arthroscopy

Loose bodies are a rare cause of temporomandibular joint symptoms. Their main source is synovial chondromatosis. We report on clinical findings, diagnostic methods, treatment choices and outcome following the removal of loose bodies in 10 patients. Seven patients were evaluated and treated by means of arthroscopy, while in three patients open arthrotomy was performed. In five patients, no diagnostic imaging technique had demonstrated the presence of loose bodies prior to arthroscopy. In six patients, histology revealed synovial chondromatosis. In four patients, osteochondral fragments alone were found. Until now, the recommended treatment of choice for the removal of all loose bodies and of affected synovial tissue required open arthrotomy. We conclude that the advantages of arthroscopy consist in locating loose bodies that are not detectable radiologically and in reducing operative trauma.

Seminoma with syncytiotrophoblastic giant cells

Testicular seminomas may occur in various forms, of which the classical and spermatocytic are distinct, the anaplastic or atypical seminomas, however, less clearly defined. Lately, a separate group of particular clinical significance, comprising seminomas with syncytiotrophoblastic giant cells (STGC), has been specified. Although this type of seminoma had been recognized morphologically long ago, recent investigations have shown its ability to secrete HCG, a fact that raises serious difficulties in its differential diagnosis with combined seminomas and choriocarcinomas. Two cases of seminomas with STGC are presented and pertinent clinical and morphologic problems discussed.

Primary leiomyosarcoma of extragnathic bones: Case report and review of literature

In a 60‐year‐old man, a swelling anteromedially just below the knee led to the discovery of an intraosseous leiomyosarcoma. It is the 13th documented case of primary leiomyosarcoma of bone outside the facial skeleton. Clinical and pathologic findings, modes of treatment and therapeutic results are reviewed, and theories of histogenesis discussed. As to the latter, ultrastructural features in our case support the pleuripotent mesenchymal rather than the vascular smooth muscle origin.

Mitotic count in seminomas — an unreliable criterion for distinguishing between classical and anaplastic types

Testicular seminomas occur in various forms of which the classical, the spermatocytic, and that with syncytiotrophoblastic giant cells are distinctly defined. Anaplastic seminomas, however, are less clearly distinguished. Forty-five seminomas, 39 pure and 6 combined tumors, were examined from the perspective of the current definition that 3 or more mitoses per high power field (m/hpf) distinguish the anaplastic from the classical form. Our resultant yield of over 80% of “anaplastic” seminomas is clearly incompatible with general clinical experience, indicating that the arbitrary criterion of 3 m/hpf does not segregate anaplastic forms from neoplasms that are mitotically active but relatively non-aggressive. Moreover, the evidence indicates that mitotic activity does not adequately define a tumor form that is near the undifferentiated end of the spectrum which extends from “embryonal carcinoma” to the spermatocytic type. If it should prove, however, that the mitotic rate must be used as an arbitrary watershed criterion until a more reliable one is found, it should then be set at more than 5 m/hpf, yielding a percentage of anaplastic seminomas (about 9%) that is compatible with clinical experience.

Primary osteosarcoma of the liver

Extraskeletal osteosarcomas are infrequent, and those that arise within parenchymal organs are very rare indeed. This case of a 71‐year‐old man with a primary osteosarcoma of the liver is the second reported in man. Pathologic findings, including ultrastructural features, at surgery and autopsy are presented. The differential diagnosis is discussed in detail.