Joel G. Lucas

The value of second opinion in gastrointestinal and liver pathology.

OBJECTIVE The value of routine second opinion review of liver and gastrointestinal pathologic material was evaluated to determine whether there were discrepancies in diagnoses and if these discrepancies had an impact on treatment or prognosis. MATERIALS AND METHODS All gastrointestinal and hepatobiliary histopathology referral diagnoses made during a 1-year period for patients being treated at Ohio State University Medical Center were compared with the outside pathologic diagnosis. All major discrepant diagnoses were reviewed by at least 2 pathologists. Diagnoses were classified as no diagnostic disagreement, diagnostic disagreement, or no diagnostic disagreement but pertinent information missing or terminology unclear. Discrepant cases were also classified according to the clinical significance of the discrepancy. RESULTS Pathology reports from 194 hepatobiliary and gastrointestinal cases were reviewed. Of the hepatobiliary cases, 57 (64.8%) of 88 cases showed no discrepancies. Discrepancies were noted in 31 cases (35.2%), including missing information or unclear terminology in the diagnosis in 23 cases (26.1%) and diagnostic disagreement in 8 cases (9.1%). Of the cases with discrepancies, 6 (6.8%) were of major significance. Of the gastrointestinal cases, 87 (82.1%) of 106 cases showed no discrepancies. Discrepancies were noted in 19 cases (17.9%), including missing or unclear information in 3 cases (2.8%) and diagnostic disagreements in 16 cases (15.1%). The cases with discrepancies included 8 cases (7.5%) for which the change was of major clinical significance. CONCLUSIONS Routine pathologic review of gastrointestinal and hepatobiliary cases revealed notable discrepancies in diagnoses. In 14 cases (7.2%), the change in diagnosis or additional information had a significant effect on the proper treatment or a significant prognostic implication. Routine review of all pertinent pathologic material should be performed on all patients being transferred to a second institution for treatment or second opinion.

Carcinosarcoma of the Urinary Bladder—An Aggressive Tumor With Diverse Histogenesis A Clinicopathologic Study of 4 Cases and Review of the Literature

OBJECTIVE Carcinosarcomas of urinary bladder are rare malignant neoplasms. Seventy-eight cases have been previously described. The histologic composition of these tumors is variable, but diagnosis requires the presence of both epithelial and mesenchymal malignant components. We report 4 additional cases, with an emphasis on unusual histologic features. METHODS Histologic and immunohistochemical examinations were performed on bladder tumors from 4 patients. Clinicopathologic features of previously reported and current cases were reviewed and summarized. RESULTS Four patients (3 men, 1 woman) age 54 to 77 years were found to have polypoid masses in the urinary bladder. In all cases, histologic examination showed biphasic neoplasms with distinct mesenchymal and epithelial components. The morphologic and immunohistochemical characteristics of the tumors varied. One of the cases was remarkable for the presence of liposarcoma, malignant peripheral nerve sheath tumor, and micropapillary urothelial carcinoma. Two of the patients died 2 years after diagnosis, which is consistent with the previously reported aggressive nature of urinary bladder carcinosarcomas. CONCLUSIONS Carcinosarcomas of the urinary bladder are rare, aggressive malignant neoplasms. To our knowledge, a liposarcomatous component has been reported in only 1 case previously, and components of micropapillary urothelial carcinoma and malignant peripheral nerve sheath tumor have not been reported previously in carcinosarcomas of the urinary bladder. Because of the aggressive biologic behavior of these tumors, they should be identified promptly and treated appropriately.

Frozen section diagnosis of pancreatic lesions.

BACKGROUND The clinical and radiologic diagnosis of pancreatic cancer and the safety of pancreatic resections have improved. These improvements, together with the indication for resection in some cases of complicated chronic pancreatitis, have reduced the necessity for confirmed preoperative tissue diagnosis. We investigated the clinical use and accuracy of frozen section diagnosis for pancreatic lesions. DESIGN We searched archival files for the years 1989-2000 for patients with pancreatic lesions who had received a diagnosis based on frozen section results. We compared the diagnosis of all frozen section slides with that of the permanent sections and reviewed the clinical follow-up notes. We evaluated histologic features useful in differentiating between malignant and benign pancreatic lesions. RESULTS A total of 538 patients underwent surgical biopsy and/or resection for suspected pancreatic lesions. Frozen section was requested in 131 cases (284 frozen sections). Ninety cases had frozen section of the pancreatic lesions, 70 cases had frozen section of metastatic sites, and 29 cases had frozen section of surgical margins. Of the 90 cases in which frozen section of the pancreatic lesions was requested, malignancy was diagnosed in 44, a benign lesion was diagnosed in 37, and the diagnosis was atypical and deferred in 9. In total, 3 false-negative frozen sections and 1 false-positive frozen section were identified for respective rates of 1.2% and 0.3%. In all cases in which the frozen section diagnosis was deferred or was inconsistent with the operative impression, and the surgeon acted on his/her impression, the operative diagnoses were subsequently confirmed by additional permanent sections and/or clinical follow-up. The most useful histologic features for the diagnosis of pancreatic adenocarcinoma in frozen sections were variation in nuclear size of at least 4:1, disorganized duct distribution, incomplete duct lumen, and infiltrating single cells. CONCLUSIONS Frozen sections are useful in conjunction with the impression at surgery for the management of patients with pancreatic lesions. Frozen sections of resection margins were 100% accurate; frozen sections of pancreatic lesions or metastatic sites were accurate in 98.3% of cases. We found an acceptable rate of deferred frozen section (6.6%). The experienced surgeons impression of malignancy is reliable in cases in which frozen section is deferred or has negative findings.

Rapid analysis of mandibular margins

Evaluating surgical margins during composite resection of carcinoma is limited by analysis of the bone margins. The standard pathologic evaluation of bone is by decalcification. A method of analysis was devised based on histologically proven methods of cortical invasion and subsequent spread. Frozen section analysis (FSA) of the cancellous bone was investigated as a rapid method of evaluating adequacy of the mandibular resection. Subjects consisted of 29 patients undergoing full‐thickness mandibular resection, with 16 cases of histologically proven mandibular invasion qualifying for evaluation. Results of FSA were then compared to the permanent section analysis of the cancellous bone and to the decalcified specimen. Complete correlation was found between frozen and permanent section results. Frozen section analysis was able to correctly predict adequacy of resection in 32 (97%) of 33 margins.

Diffuse leiomyomatosis of the uterus: a case report with clonality analysis

Diffuse uterine leiomyomatosis is a rare condition distinguished from the common uterine leiomyomata by involvement of the entire myometrium by innumerable, ill-defined, often small and confluent, histologically benign smooth-muscle nodules. Fourteen cases have been previously described in the literature. We report a case of diffuse leiomyomatosis in a 39-year-old woman. Several microscopic foci of the process were microdissected for clonality analysis. All samples showed a non-random X-chromosome inactivation pattern, and thus were consistent with a monoclonal neoplastic population of cells. However, in different foci of tumor, different X chromosomes were inactivated, supporting the independent origin of neoplastic clones and rejecting the possibility of a single clonal origin of all tumor cells. The results of the molecular analysis suggest that diffuse uterine leiomyomatosis may be an exuberant example of diffuse and uniform involvement of the entire myometrium by multiple leiomyomata. HUM PATHOL 31:1429-1432.

Detection of aerosolized cells during carbon dioxide laparoscopy

Laparoscopic surgery for malignancy has been complicated by port-site recurrences. The exact mechanism has yet to be defined. In vitro studies suggest that carbon dioxide-induced tumor cell aerosolization may play a role. We have attempted to document this in a human model. Patients scheduled for elective laparoscopy underwent port placement and abdominal insufflation with carbon dioxide. A suction trap was then filled with 40 cc of normal saline solution and attached to an insufflation site on the port. The carbon dioxide effluent was directed through the sahne. The specimen was concentrated, resuspended, and transferred to a slide. A Papanicolaou stain was used. Thirty-five specimens were obtained. Fifteen patients (37%) had malignant disease, which was metastatic in eight. Five patients had carcinomatosis. In two of those with carcinomatosis, staining revealed a large number of malignant cells. Malignant cells were not found in any other patients. In two patients, however, aerosolized mesothelial cells were identified. Follow-up ranged from 2 to 7 months. One patient who displayed cellular aerosolization developed a port-site recurrence. We conclude that malignant cells are aerosolized but only during laparoscopy in the presence of carcinomatosis. It is unlikely that tumor cell aerosolization contributes significantly to port-site metastasis.

Soft tissue hemangioma with adjacent periosteal reaction simulating a primary bone tumor.

A previously healthy 9-year-old boy presented with pain and swelling in the dorsal aspect of his proximal left forearm. The pain was characterized as a constant, dull ache that had persisted for 6 weeks despite conservative therapy. There was no history of trauma. Constitutional symptoms such as fever, anorexia, or weight loss were notably absent. His past medical history was unremarkable. On physical examination, an illdefined, mobile, soft tissue mass was palpated over the dorsum of the proximal left forearm. On light palpation, the mass was soft and uniform in consistency, but a hard, fixed protuberance adjacent to the proximal ulna was felt on deep palpation. The overlying skin was normal in color and pallor with no identifiable rash. The elbow had a normal range of motion. No axillary lymph nodes Skeletal Radiol (1996) 25:174–177

Bladder Wall Calcification after Intravesical Mitomycin C Treatment of Superficial Bladder Cancer

Calcification of the bladder wall associated with intravesical mitomycin C for the treatment of superficial bladder cancer is a rare complication. We report on a patient with this complication and discuss the literature.

Splenic rupture: a rare presentation of pancreatic carcinoma.

CONTEXT Splenic rupture secondary to solid malignancy is an infrequent complication that usually occurs late in the progression of a previously diagnosed cancer. In rare instances, splenic rupture precipitates the discovery of an unsuspected pancreatic carcinoma. We report 2 cases of adenocarcinoma of the pancreas in which the patients presented with splenic rupture. OBJECTIVES To review the clinicopathologic features of splenic rupture due to pancreatic carcinoma and to increase awareness of malignancy as a possible etiology for atraumatic splenic rupture. DESIGN We reviewed the clinical and pathologic data from 2 patients. A literature search was conducted to identify previous reports of splenic rupture associated with pancreatic cancer. We summarized the characteristics of the earlier cases and compared them with those of our patients. RESULTS We found only 4 previous reports of splenic rupture preceding the diagnosis of pancreatic cancer. In 3 of these cases, the pancreatic carcinoma grossly invaded the spleen at the time of resection. In contrast, malignancy was not suspected as the etiology of the rupture in our patients until histologic examination of the resected spleen revealed carcinoma. CONCLUSION Splenic rupture is an unusual presentation of cancer of the pancreas, and to our knowledge only 4 cases have been reported previously in the literature. Although an underlying malignancy is relatively rare, spleens resected for atraumatic rupture should be carefully examined for possible neoplastic etiologies.

Unusual giant cell tumor arising in a male breast

An unusual giant cell tumor of the breast of a 72 year old man is reported. The microscopic and ultrastructural features of the tumor are presented in detail. Unusual and previously unreported myofibroblastic an myoepithelial differentiation of the spindle cell component is described. The possible histogenesis of the tumor is discussed.