Bimal C. Ghosh

Castleman's disease in the head of the pancreas: report of a rare clinical entity and current perspective on diagnosis, treatment, and outcome

BackgroundCastlemans disease of the pancreas is a very rare condition that may resemble more common disease entities as well as pancreatic cancer.Case presentationHere we report the case of a 58-year-old African American male with an incidentally discovered lesion in the head of the pancreas. The specimen from his pancreaticoduodectomy contained a protuberant, encapsulated mass, exhibiting microscopic features most consistent with localized/unicentric Castlemans disease. These included florid follicular hyperplasia with mantle/marginal zone hyperplasia along with focal progressive transformation of germinal centers admixed with involuted germinal centers.ConclusionTo date, eight cases of Castlemans disease associated with the pancreas have been described in the world literature. We report the first case of unicentric disease situated within the head of the pancreas. In addition, we discuss the diagnostic dilemma Castlemans disease may present to the pancreatic surgeon and review current data on pathogenesis, treatment, and outcome.

Ultrastructural study of stroma in human mammary carcinoma.

This investigation was designed to study the origin of the stromal component of human mammary carcinoma. Tissues from 30 proved breast carcinomas were studied. Under a light microscope with special stains, an increased connective tissue component was seen in carcinoma. Gluteraldehyde-fixed tissue was examined under an electron microscope. The stroma appeared to be composed of fibroblastic, myofibroblastic, histiocytic and primitive mesenchymal cells. Elastic fibers were intimately intermingled with collagen and reticulin and seen in close association with carcinoma cells. In some areas they were seen inside the carcinoma cells with discontinuous cytoplasmic membrane, as if they were formed by the cancer cells. This observation suggests that breast carcinoma cells play an important role in the production of elastic fibers in association with stromal cells and also stimulate the proliferation of the stromal cellular component.

The management of the unknown primary1

The clinical presentation of cancer is heterogeneous with respect to biology, pathologic features, and responsiveness to cytotoxic treatment. Although some malignancies may be diagnosed early in their course, others present at an advanced stage with tumor metastases as the first sign of a malignant process. When tumors present at an advanced stage, taking a history, performing a physical examination, and conducting a directed diagnostic workup might identify the primary tumor site. But, in other instances, the source of the metastatic tumor cannot be identified despite this directed search. In this scenario, a diagnosis of metastatic cancer of unknown primary should be entertained. The definition of metastatic cancer of unknown primary is a biopsy-confirmed malignancy for which the site of origin is not identified by routine workup. This workup includes a complete history and physical examination. Additionally, this workup includes routine laboratory studies, chest x-ray, digital rectal examination with test for stool occult blood, and standard pathologic evaluation of the specimen. Women should undergo breast and pelvic examination, and men should have a complete prostate and testicular examination. The diagnosis of metastases of unknown primary site makes up 5% to 10% of all cancer patients, making it the seventh most common malignancy. The primary lesion, which has escaped detection by a staging workup, can be identified in only 30% to 82% of cases at autopsy. This inability to detect the primary tumor has two possible explanations. The first hypothesis is that the primary has involuted and is not detectable when the metastasis becomes evident. Although this is not a common phenomenon, spontaneous tumor regression has been described in several tumors. The second explanation is that the primary tumor’s malignant phenotype and genotype favor metastatic ability over local tumor growth. In this scenario, a slow-growing primary tumor might produce early metastatic lesions whose growth outstrips that of the parent tumor. This scenario of an unknown primary can be very unsettling to both the patient and the treating physician. The anxiety provoked by this clinical scenario may be caused by the uncertainty over treatment and an assumption of a grim prognosis, because current cancer treatment has been based on the identification of the primary tumor, but this disease entity actually represents a group of diseases with potentially widely divergent prognoses. When grouped together, patients with metastases from an unknown primary site have a median survival of approximately 6 months, despite therapy, but it is important to recognize that there are certain patient subgroups that have more responsive tumors and better prognoses. It is essential to conduct a consistent and thorough diagnostic evaluation to determine if a patient falls into one of these favorable subgroups, although one should avoid the use of needless, invasive tests. This approach enables the physician to optimize the treatment regimen for each patient. We describe the appropriate diagnostic workup of patients with metastases from an unknown primary site with emphasis on identification of patients with a favorable prognosis, and we highlight the treatment options available. Cases of metastases from an unknown primary usually fall into two possible categories: metastatic involvement to lymph nodes only, and those with visceral involvement. The most common sites for involvement of metastatic disease are to the lymph nodes, lung, bone, or liver. This is an important distinction because the patients with isolated nodal metastasis have a better prognosis with appropriate therapy.

Stereotactic Breast Biopsy as an Alternative to Excisional Biopsy

Abstract. The current widespread use of modern mammography has increased the detection of suspicious mammographic lesions, which has led to a greater number of diagnostic surgical biopsies. Most of these lesions referred for surgical biopsy have been benign. The reduction in the number of benign surgical biopsies can reduce medical costs and unnecessary invasive breast surgery. Stereotactic large-core needle biopsies in patients with suspicious mammographic lesions can preselect the breast lesions that need further evaluation with surgical excisional biopsy. Our results with stereotactic large-core needle biopsies support this alternative approach to the workup of suspicious mammographic lesions.

Adjuvant treatment of colorectal cancer

SummaryColorectal cancer is the second leading cause of cancer mortality in the United States, causing approximately 50,000 deaths per year. The overall prognosis and results of treatment have not changed impressively over the last three decades. Half of all the patients who undergo curative surgery finally succumb to locoregional or metastatic recurrence of their disease. Recent clinical research has been aimed at adjuvant therapeutic measures to improve survival after curative surgical resection.For rectal cancer, combined postoperative chemotherapy and radiation therapy have been shown to reduce the overall relapse rate and improve disease-free survival. Further studies of adjuvant treatment for rectal cancer are needed to evaluate the optimal radiation schedule and limit the side-effects of the treatment.Adjuvant treatment of colon cancer must still be regarded as unsettled. Since liver metastases are the most common unfavorable outcome of colon cancer, ongoing trials using liver-directed treatment (perfusion, irradiation) should be followed with interest. The lack of proven efficacy and the side-effects of these treatments strongly favor the inclusion of an observation-only control group in trials for adjuvant treatment of colon cancer.Unfortunately, there is a yet no, proven significant benefit from immunotherapy as an adjuvant therapy for colorectal cancer, but further basic and clinical studies will be of great interest in this field.

Stratification of palpable and nonpalpable breast cancer by method of detection and age

AbstractBackground: Methods used to diagnose breast cancer in women under the age of 50 years are somewhat controversial. To determine the relationship between type and stage of breast cancer, clinical presentation, and age, we reviewed breast cancer diagnosed at our institution during a recent 3-year period. Methods: Records from 589 consecutive excisional biopsies and 372 needle placement biopsies performed over a 3-year period were reviewed. Carcinomas were staged according to the TNM system and results compared usingx2. Results: Breast carcinoma was diagnosed in 118 women during the study period, 33% in patients under 50 years of age. Breast cancer diagnosed by mammography in all age groups was more likely to be noninvasive than that diagnosed by physical examination (p<0.05). The few invasive cancers diagnosed by mammography in women under age 50 were lower in stage than those diagnosed by physical examination, although not by a statistically significant amount (p=0.125). Breast cancer diagnosed by mammography in women 50 years and older was significantly lower in stage than that diagnosed by physical examination (p<0.05). Conclusions: Invasive carcinoma detected as a nonpalpable lesion by mammography was earlier in stage than invasive carcinoma detected by physical examination, including in women under 50 years of age, although the number of invasive cancers detected in younger women was quite small. The role of mammography in this younger age group remains to be defined.

Role of angiography in the diagnosis of pancreatic neoplasms

The vascular architecture of the pancreas has been described, but few reports indicate preoperative accuracy. During the last 3 years, selective superior mesenteric and celiac angiography was performed in 471 patients. In 35 of these patients, additional selective angiography of the superior pancreaticoduodenal and inferior pancreaticoduodenal arteries was performed to reveal the detailed vascular pattern of the pancreas and its surrounding structures. Exploratory surgery was performed in all patients except the four control subjects. The angiographic findings reflected a poorly vascularized infiltrating lesion with invasion of the blood vessels and serpiginous encasements. Peripancreatic extension of the tumor indicated nonresectability. In early pancreatitis, the pancreas showed increased vascularity and occasional stretched vessels. In more advanced pancreatitis, the arteries were prominent and irregular with increased parenchymal accumulation of contrast medium in the capillary phase. In pseudocysts of the pancreas, the only finding was stretching of the vessels around the lesion. A well circumscribed lesion with increased contrast medium in the capillary and venous phases diagnostic of pancreatic adenoma. Pancreatic angiography is an important diagnostic tool in evaluating and staging pancreatic neoplasms.

Vertebral venous air embolism: an unusual complication following colonoscopy: report of a case.

Although fiberoptic colonoscopy has gained wide popularity as a diagnostic and therapeutic tool, there remains an inherent complication rate following colonoscopic evaluation. Endoscopically induced bowel perforation and uncontrolled bleeding often necessitate immediate surgical intervention. Another often-unrecognized complication is the introduction of air into the vertebral venous system. A case of vertebral venous air embolism after routine diagnostic colonoscopy is reported with a review of current literature.

Germ cell testis cancer: 15-year review

Testis cancer affects 2–3 men per every 100,000 in the United States, making it the most common solid tumor of men in the 20–35‐year‐old age range. Since the average age of active duty military personnel is included in the age range of those at greatest risk for germ cell testis cancer, it is of pertinent clinical importance to physicians who treat these young patients. The National Naval Medical Center has been using cisplatin‐based protocols since the time of their introduction. This study reviews the success of treating these patients and examines the treatment failures.

Intracellular demonstration of growth hormone in human mammary carcinoma cells.

Intracellular growth hormone has been demonstrated in human mammary carcinoma cells by using an unlabeled antibody enzyme technic with horseradish peroxidase and antihorseradish peroxidase complex. Intense reaction was seen in both male and female mammary carcinoma cells. Positive staining was observed in nuclei and cytoplasm and on cytoplasmic membranes.