Bruce A. Sebek

Interobserver reproducibility among neuropathologists and surgical pathologists in fibrillary astrocytoma grading

UNLABELLED Many of the problems associated with the current grading approaches for fibrillary astrocytomas center around the lack of consistency in grading. This study compares the diagnoses of five neuropathologists with five experienced surgical pathologists with regard to assigning astrocytoma grade. Thirty neoplastic and non-neoplastic lesions were sent to each of five neuropathologists and five surgical pathologists for placement into one of three grades as outlined by modified Ringertz schema. Grading criteria (Burger et al., 1985. Cancer 56:1106-1111) were distributed to all participants, who have been practicing for at least 5 years. An additional category for non-neoplastic or normal tissue was also provided. The diagnoses, based on the majority opinion of the neuropathologist group, included six low grade astrocytomas, 11 anaplastic astrocytomas, seven glioblastoma multiforme, and six normal/reactive lesions. Agreement by all neuropathologists was reached in 12 cases (40%). A discrepant diagnosis was obtained in one of five neuropathologists in 14 additional cases (46.7%). In the remaining four cases, two neuropathologists deviated from the majority opinion; in each of these cases, the diagnostic problem involved differentiating tumor from reactive gliosis. All five surgical pathologists agreed in six cases (20%). One discrepant diagnosis among the surgical pathologist group was seen in seven cases (23.3%). In the remaining 17 cases, two or more discrepant diagnoses were obtained (56.7%); discrepancies in these cases included differences in assignment of tumor grade and in distinguishing low grade astrocytoma from gliosis. IN CONCLUSION (1) it is likely that experience with grading accounts for the better level of agreement among the neuropathologist group (kappa statistic 0.63) versus the surgical pathologist group (kappa statistic 0.36); (2) in most cases, the neuropathologists all agreed or had one discrepant diagnosis (86.7%) versus the surgical pathologist group (43.3%); (3) the discrepancies in diagnosis among both groups is likely related, in good part, to the limitations of the grading schema in fully enumerating the spectrum of such grading parameters as cytologic atypia and vascular proliferation.

Mastitis Due to Mycobacterium abscessus after Body Piercing

We describe a patient with granulomatous mastitis due to Mycobacterium abscessus that presented as a mass lesion and was associated with a pierced nipple. To our knowledge, this is the first reported case of mastitis due to M. abscessus and the first association of this organism with body piercing.

Nasal tuberculosis: A forgotten entity†‡

Tuberculosis of the nose has become so infrequent that it is virtually a forgotten disease entity among younger practitioners in this country. Nevertheless, it can occur in all segments of our population and may present a confusing diagnostic problem. Two cases of primary nasal tuberculosis have been diagnosed and treated at The Cleveland Clinic Foundation since 1975. The differential diagnosis of nasal granulomatous disease usually includes Wegeners granulomatosis, midline malignant reticulosis, and sarcoidosis. We point out the necessity of including tuberculosis in this differential diagnosis. The definitive work‐up and treatment are also discussed.

The contrecoup phenomenon: Reappraisal of a classic problem

We describe briefly and comment upon the salient strengths and limitations of the major published theories that purport to explain the mechanism of contrecoup cerebrocortical contusions. Through the application of mechanical principles, we then present a modification, clarification, and expansion of selected aspects of several theories. Our final formulation emphasizes the injurious potential of nonuniform compressive stress and the relationship between brain lag and rotationally induced injury. The resulting theory remains faithful to the laws of physics while explaining the location and distribution of cerebrocortical contusions opposite the site of a moving head impact.

Mucosal regeneration of the maxillary sinus after surgery

The postsurgical effects of the removal of the maxillary sinus mucosa were studied in an animal model. Ten rabbits underwent Caldwell-Luc procedures with the removal of all the maxillary sinus mucosa from one sinus, while the other sinus in each animal was used as a control. After allowing time for postsurgical healing, animals were examined for mucociliary transport and sections for histologic examination were obtained. Respiratory ciliated epithelium was present in seven of the postsurgical sinuses. Marked increases in acute and chronic inflammation, granulation, fibrosis, and ulcerations were noted.

Osteosarcoma of the Hand

Two cases of osteogenic sarcoma in the hand are reported, with a discussion of the literature.

Parotid gland malignant melanomas

BACKGROUND Malignant melanomas are relatively unusual tumors in the parotid gland. The majority of previously reported cases appear to represent metastatic lesions, often from cutaneous head and neck primaries. METHODS Retrospective clinicopathologic review of 12 cases of malignant melanoma involving the parotid gland encountered between 1980 and October 1999 at a tertiary referral center. RESULTS Patients consisted of 9 men and 3 women ranging in age from 30 to 84 years (median, 66 years). Eleven of 12 patients presented with a neck mass or nodule. In 9 of 12 patients, a cutaneous or conjunctival primary was noted in the head region. In 2 patients, a cutaneous melanoma and the parotid gland melanoma were diagnosed at the same time. In 1 patient, melanoma was initially diagnosed in the parotid gland, and a definite primary was not uncovered. All patients underwent excision of the parotid melanoma, which was accompanied by a lymph node biopsy or dissection in 10 out of 11 patients. Four patients received adjuvant radiotherapy, and 3 patients received adjuvant chemotherapy. Four of 11 patients had ipsilateral cervical lymph node metastasis at the time of parotid tumor resection, and 5 patients had involvement of intraparotid lymph nodes by metastatic melanoma. Tumors ranged in size from 0.3 to 2.5 cm in greatest dimension. Multiple parotid nodules were noted in 4 patients. All tumors were characterized by a diffuse proliferation of cells with abundant eosinophilic cytoplasm and prominent nucleoli. Four tumors demonstrated focal spindle cell regions. Intravascular and/or lymphatic involvement by tumor within the parotid gland was noted in 3 lesions. At last known follow-up, 6 patients had died with tumor at a median follow-up period of 11 months after parotid gland surgery. Four patients were alive with evidence of tumor at follow-up intervals of 4, 17, 21, and 113 months after parotid gland surgery. Two patients were alive with no evidence of residual tumor at 20 and 148 months of follow-up. CONCLUSIONS The majority of melanomas involving the parotid gland appeared to be associated with lymph node metastasis in and around the gland from a cutaneous primary in the head region. Prognosis is generally poor, although rare patients may survive a long period of time following surgery.

Acute nonlymphocytic leukemia in patients receiving chemotherapy for nonmalignant diseases

The occurrence of acute leukemia in patients receiving chemotherapeutic agents for malignant disease has been well established. Recent reports have suggested that chemotherapeutic drugs used to treat inflammatory conditions may have an oncogenic potential. From 1969 to 1977, 11 patients with a variety of collagen-vascular diseases who developed acute nonlymphocytic leukemia were seen at the Cleveland Clinic. Rheumatoid arthritis was the most common underlying disease, in addition to giant cell arteritis, polyarteritis nodosa, chronic glomerulonephritis, and scleroderma. All patients were treated with alkylating agents, and 10 of the 11 received multiple cytotoxic agents. According to the French-American-British classification there were six examples of M4 (myelomonocytic leukemia), with single examples of M1 (myeloblastic leukemia without maturation), M2 (myeloblastic leukemia with maturation), M5a (monocytic leukemia, poorly differentiated), M5b (monocytic leukemia, differentiated), and M6 (erythroleukemia). Cytogenetic studies were abnormal in five patients studied, showing varying degrees of aneuploidy. All patients died, and the mean duration of time from the diagnosis of leukemia to death was four and one-half months, with only one complete remission.

Primary squamous cell carcinoma of the parotid gland

Primary squamous cell carcinoma of the parotid gland is an uncommon malignancy. It can be diagnosed only after squamous cell carcinoma metastatic to the parotid gland has been excluded. Histologic evaluation must differentiate primary squamous cell carcinoma from high‐grade muco‐epidermoid carcinoma or adenocarcinoma. Retrospective review of parotid gland neoplasms seen in the Department of Otolaryngology and Communicative Disorders between 1972 and 1987 identified eight cases for an incidence of 1.8%. The majority of these patients had advanced disease and were treated with both surgery and radiation therapy. Fifty percent of the cases demonstrated no evidence of disease at an average follow‐up of 29 months.

PRIMITIVE NEUROECTODERMAL TUMOR OF THE KIDNEY WITH INFERIOR VENA CAVA AND ATRIAL TUMOR THROMBUS

Primitive neuroectodermal tumor of the kidney is a rare malignancy. We report a case of renal primitive neuroectodermal tumor with a level IV inferior vena caval thrombus that was managed successfully with deep hypothermic circulatory arrest. CASE REPORT A 55-year-old woman presented with vague left lower quadrant discomfort. Physical examination and laboratory tests were unremarkable. Computerized tomography (CT) of the abdomen and pelvis revealed a 5.7 4.7 cm. heterogeneously enhancing right renal mass with thrombus noted in the right renal vein extending superiorly to the level of the right atrium (fig. 1). Transesophageal echocardiography confirmed a large right atrial thrombus. Chest CT showed a 2.5 cm. left lower lobe mass, which on biopsy demonstrated benign fibro-connective tissue. The patient underwent right radical nephrectomy and level IV inferior vena caval thrombectomy with cardiopulmonary bypass and deep hypothermic circulatory arrest. Gross examination revealed a firm 5.2 cm. mass in the right kidney. Microscopically there were sheets and lobules of cells with round to oval nuclei and coarse chromatin, as well as Homer Wright rosette formation. Immunohistochemical analysis showed strongly positive staining for CD99 (fig. 2) and negative staining for other neuroendocrine markers such as synaptophysin and chromogranin. No molecular analysis was performed on the specimen. Presently the patient remains disease-free at limited followup 5 months postoperatively. Repeat CT of the chest, abdomen and pelvis before starting chemotherapy was negative for metastatic disease, and the previously noted chest lesion was found to be unchanged in size. The patient has completed 2 cycles of ifosfamide, cyclophosphamide and doxorubicin, and has tolerated the chemotherapy well without significant side effects. DISCUSSION