Austin L. Vickery

Mucinous carcinoma of the colon and rectum

The clinicopathologic significance of mucus production by adenocarcinoma of the colon and rectum was analyzed in retrospective study with stage matched non‐mucus producing control carcinomas. Mucinous carcinoma of the colon and rectum comprised 132 (15%) of 893 cases of colorectal carcinoma. The rectum was the most common site (33% of cases). While 120 mucinous cancers had a poorer five‐year survival than non‐mucinous tumors (34% vs. 53%, p <.005), these had a particularly bad prognosis in the rectum (18% 5 year survival vs. 49% for the non‐mucinous tumor controls, p <.005). The theoretical basis for this location‐dependent behavior is considered. From this study, distinctive clinico‐pathologic features emerge. There were seven documented cases of ulcerative colitis and 8 additional patients gave a history of “colitis”. An additional five patients had received prior pelvic irradiation. Of particular note was the fact that 31% of mucinous carcinomas were associated with villous adenomas, implying a histogenetic relationship. Moreover, this finding again emphasizes the neoplastic potential of the villous adenoma, especially in the rectum where the development of mucinous carcinoma is particularly ominous.

Loss of The Retinoblastoma Tumor-Suppressor Gene in Parathyroid Carcinoma

BACKGROUND The origin and molecular pathogenesis of parathyroid carcinoma are unknown. This life-threatening cause of primary hyperparathyroidism cannot be reliably distinguished from its benign counterpart on the basis of histopathological features alone. Because the PRAD1, or cyclin D1, gene, a cell-cycle regulator, has been implicated in a subgroup of benign parathyroid tumors, we examined the possibility that another cell-cycle regulator with possible functional links to PRAD1, the retinoblastoma tumor-suppressor gene (RB), might be involved in the molecular pathogenesis of parathyroid carcinoma. METHODS Parathyroid carcinomas from 9 patients and adenomas from 21 were studied for evidence of tumor-specific loss of RB gene DNA (allelic loss) by analysis of four DNA polymorphisms and for evidence of altered expression oF RB protein by immunohistochemical staining. RESULTS All of 11 specimens from 5 patients with parathyroid carcinoma and informative DNA patterns and 1 of 19 specimens from 19 patients with parathyroid adenoma and informative DNA patterns lacked an RB allele. Fourteen of 16 specimens (88 percent) from the nine patients with carcinoma had abnormal expression of RB protein (a complete or predominant absence of nuclear staining for the protein). None of the 19 adenomas, including the tumor with loss of an RB allele, had unequivocally abnormal staining for RB protein. CONCLUSIONS Inactivation of the RB gene is common in parathyroid carcinoma and is likely to be an important contributor to its molecular pathogenesis. The presence of such inactivation may help to distinguish benign from malignant parathyroid disease and may have useful diagnostic, prognostic, and therapeutic implications.

The fibrous variant of Hashimoto's thyroiditis

Abstract The fibrous variant of Hashimotos thyroiditis presents a clinicopathologic picture quite distinct from that of typical Hashimotos disease. Fifty-six patients with this entity are described, and these represent 12.5 per cent of all cases with a pathologic diagnosis of Hashimotos thyroiditis. The lesion is characterized by a marked fibrous replacement of one-third to the majority of the parenchyma and changes typical of Hashimotos disease in the remaining tissue. In contrast to Riedels struma, there is no extension of the fibrotic process beyond the thyroid capsule, and the dense hyaline form of connective tissue differs from the active proliferative fibrosis seen in Riedels thyroiditis. The lesion may be mistaken for cancer with islands of metaplastic epithelium in the fibrotic tissue simulating foci of carcinoma cells. Distinctive clinical features include a very firm goiter, often with a striking recent enlargement, severe neck pressure symptoms, frequent diagnostic confusion with malignant disease, and a markedly elevated tanned red cell antibody titer to thyroglobulin. These titers often tend to parallel a history of recent thyroid growth and the degree of fibrosis on sequential needle biopsy studies. The similarities and possible relationship between the fibrous variant of Hashimotos thyroiditis and idiopathic primary myxedema are discussed.

Tinctorial and Morphologic Properties Distinguishing Actinomycosis and Nocardiosis

Abstract Actinomycosis and nocardiosis in visceral infections are distinguished usually on the basis that Actinomyces israelii is not acid fast, but is associated with sulfur granules, whereas Nocardia asteroides is often acid fast, and may be associated with sulfur granules. Because of a case of cultureproved actinomycosis, in which sulfur granules and acid-fast organisms were found, the reliability of these criteria was examined. Materials from four cases of actinomycosis and one culture of A. israelii were stained with the classic Ziehl -Neelsen acid-fast method and with the Putt modification. Every specimen was acid fast with the Putt, but not with the Ziehl-Neelsen method. This suggests that both A. israelii and N. asteroides may be acid fast under certain conditions and may be indistinguishable by these stains. Review of the English literature on nocardiosis showed sulfur granules reported only in infections of skin and not in viscera. Thus, the presence of the granules in viscera suggests actinomyc...

Treatment of intrathyroidal papillary carcinoma of the thyroid

Among 237 patients with grossly noninvasive (intrathyroidal) papillary carcinoma of the thyroid treated by surgery at the Massachusetts General Hospital and followed for a median of 14 years, no patient had tumor recurrence either in the thyroid bed or opposite lobe. There were 12 metastatic recurrences with risks of recurrence 4.0% and 6.9% at 10 years and 20 years respectively. Eight of these recurrences were restricted to cervical lymph nodes and did not herald the development of more serious recurrent disease. The remaining recurrences were lung metastases in four patients, two of whom died, accounting for the only deaths from thyroid carcinoma in this series. Factors that influenced the risk of recurrence included lymph node metastases at initial surgery, large tumor size, and to a lesser extent, male sex. The majority of patients (176) had subtotal thyroidectomies, mostly lobectomy (131 patients). There was no evidence that the 61 patients who underwent total thyroidectomy fared better than those with similar patient and tumor characteristics on whom subtotal procedures were performed. The overall findings of this study strongly support the concept that intrathyroidal thyroid carcinoma can be successfully treated by conservative surgery.

Adrenal pseudocyst: A clinical and pathologic study of eight cases

Adrenal pseudocysts are cystic lesions arising within the adrenal gland surrounded by a fibrous tissue wall devoid of a recognizable lining layer. This study comprised eight adrenal pseudocysts surgically excised at the Massachusetts General Hospital. The median age of the patients was 41 years. Seven of the eight individuals were women. There was no apparent etiologic relationship to prior trauma or pregnancy. Half of the patients described symptoms that resolved following pseudocyst removal. The remaining individuals were asymptomatic with adrenal pseudocysts discovered incidentally during the work up of other medical problems. Adrenal pseudocyst size ranged from 1.8 to 10 cm. Pseudocyst size did not correlate with the presence of symptoms. The histologic and immunohistochemical findings in this study suggest that at least some adrenal pseudocysts are of vascular origin. In two lesions, small foci of residual cells lining the inner pseudocyst wall were found that expressed factor VIII antigen (also Ulex Europaeus lectin in one case) but not vimentin, keratin, or epithelial membrane antigen. In both cases, abundant elastic tissue was present in the pseudocyst wall, and in one lesion, adrenal vein smooth muscle was present as well. In both cases, dilated sinusoids were found at the periphery of the pseudocysts and, in one lesion, the sinusoids appeared to coalesce to form the pseudocyst cavity. In the majority of the remaining six cases there was also some histologic evidence to suggest a vascular origin. In five and three cases, respectively, abundant elastic tissue and adrenal vein smooth muscle were found within the pseudocyst wall. In two lesions, both elastic tissue and smooth muscle were present. In addition, adrenal sinusoids were prominently dilated at the periphery of four pseudocysts and, in one case, the sinusoids appeared to coalesce to form the pseudocyst cavity.

Epithelial-lined (true) cyst of the adrenal gland: A case report

A case of an epithelial-lined (true) adrenal cyst is reported. Although over 300 adrenal cysts have been reported in the literature, true cysts are rare. In this case, a 4.0 cm cyst lined by cuboidal to flattened cells with bland cytologic features was incidentally found at autopsy. Immunologic studies performed on formalin-fixed, paraffin-embedded sections demonstrated that the cells expressed keratins (AE1/AE3+, CAM 5.2+, and MAK-6+) and were negative for epithelial membrane antigen, vimentin, factor VIII, and desmin. Normal adrenal cortical and medullary cells did not express keratins, suggesting that the cyst lining was not derived from either adrenal cortex or medulla. A mesothelial origin, with a pathogenesis analogous to the formation of primary cysts of the spleen, is proposed.

Case 3-1972

Presentation of Case A 21-year-old man was admitted to the hospital because of an abdominal mass. Four and a half years previously ulcerative colitis developed, with bloody diarrhea, fever and abdo...

Carcinoma of the prostate gland. An anatomical study of tumor location

A series of 25 prostate glands removed by radical perineal prostatectomy because of clinically evident carcinoma was examined by means of multiple whole‐gland sections to delineate localization of tumor in relation to intact anatomical landmarks. Multiple foci of tumor origin were found in 6 prostate glands (24%)—2 foci in 4 cases and 3 foci in 2 cases. Various definitions of the “posterior lobe” have given rise to confusion and disagreement regarding sites of origin of carcinoma within the prostate gland; in the present series there was no evident predilection for origin of carcinoma in the anatomic posterior lobe. The peripheral or subcapsular region of the prostate gland was the common site of origin in contrast to the periurethral region. Lymphatic invasion was present in 31 of the 33 carcinomas (94%).

A comparative study of flow cytometry and histopathologic findings in thyroid follicular carcinomas and adenomas.

As a possible diagnostic aid in the often difficult histopathologic distinction of thyroid follicular carcinomas from adenomas based on invasion most flow cytometry studies have indicated a higher aneuploidy incidence in carcinomas. However, these reports often are difficult to analyze mainly due to nonuniformity of pathologic diagnostic criteria. The present study compares the flow cytometry results of 65 follicular tumors with pathologic findings based on the World Health Organizations specific diagnostic and staging criteria. Aneuploidy was significantly higher in the 28 cancers than in the 27 hypercellular (fetal and embryonal) adenomas (57% v 22%; P = .02). There was a high percentage of aneuploidy (75%; nine of 12 cases) in the widely invasive follicular carcinomas, compared with 40% (six of 15 cases) in the minimally invasive carcinomas, 22% (six of 27 cases) in the hypercellular adenomas, and 10% (one of 10 cases) in the normofollicular or macrofollicular adenomas. However, aneuploidy was not significantly different between the most difficult differential histopathologic diagnoses of minimally invasive follicular carcinoma (40%; six of 15 cases) and hypercellular adenoma (22%; six of 27 cases) (P = .12). Other data included relatively high frequencies of aneuploidy in hypercellular adenomas (29%; six of 21 cases) and diploid status of carcinomas (36%; 12 of 33 cases). In summary, although the overall findings show a trend toward increasing aneuploidy from well-differentiated and hypercellular adenomas to minimally and widely invasive follicular carcinomas, the aneuploidy data are inconsistent and indicative of its nonspecificity and limited diagnostic usefulness.