Lawrence J. McCormack

Natural history of renal arterial disease.

Information about the natural history of renal arterial disease is important for the approach to a precise selection of hypertensive patients for medical or surgical therapy. Surgery carries a high risk of myocardial infarction and stroke in patients with renal atherosclerosis and associated coronary and cerebrovascular disease. Moreover, technical problems arise when the arterial disease affects branches of the renal artery, is bilateral, or affects the renal artery supplying a solitary kidney. Although antihypertensive drug therapy has proved effective in controlling blood pressure in patients with renal vascular hypertension (1), concern may arise that renal function deteriorate because of progression of the arterial disease. This report presents the information obtained in 91 patients studied by serial renal arteriography for periods ranging from six months to ten years. Clinical Material, Method, and Criteria of Study The 91 patients (32 males and 59 females) in the study were admitted to the Clevela...

Aspiration Biopsies of Chest Lesions

1223 patients underwent aspiration biopsy with a diagnostic yield of 86.4%; 24.2% of the patients had a small pneumothorax, but only 4.4% required treatment; one patient developed a moderate hemothorax. The method, problems, and complications including morbidity and mortality are discussed. The relative success of aspiration biopsy with different lesions of the lung and mediastinum is identified.

A pathologic-arteriographic correlation of renal arterial disease

Abstract A study of the microscopic features of occlusive renal arterial lesions in 97 patients has shown the advantage of classifying these diseases according to their primary locations in the arterial wall and the types of tissue they comprise. Two lesions were primarily intimal, atherosclerosis and intimal fibroplasia, and three were predominantly medial, medial fibroplasia, fibromuscular hyperplasia, and subadventitial fibroplasia. This classification permitted a close correlation with renal arteriographic features. Atherosclerotic lesions were either circumferential or eccentric plaques, sometimes complicated by thrombosis or dissecting aneurysm. They occurred predominantly in men. Arteriograms showed stenosis of the orifice, with poststenotic dilatation; the presence of thrombosis or dissecting aneurysm was usually indicated by complete obliteration. Intimal fibroplasia was characterized by fibrous intimal hyperplasia associated, at times, with disruption of the internal elastic membrane. Arteriographic features depended on the condition of this membrane; when it was disrupted, an aneurysm formed, producing an irregularly dilated artery. Medial fibroplasia with aneurysms produced the “string-of-beads” arteriogram previously attributed to fibromuscular hyperplasia. The “beads” were aneurysms that developed because segments of the arterial wall were absent, permitting focal dilatations. These thin segments alternated with areas in which the media had been largely replaced by collagen. Muscular hyperplasia was not present. Fibromuscular hyperplasia was an uncommon lesion resulting from increased amounts of fibrous and muscular tissue; it was sometimes accompanied by disruption of the internal elastic membrane. Arteriograms showed either symmetrical stenosis or, when the internal elastic membrane was disrupted, an irregularly dilated artery. We could find no arteriographic features that would differentiate this lesion from intimal fibroplasia. Subadventitial fibroplasia was characterized by dense collagenous thickening of the outer media irregularly replacing the muscular layer; it affected long segments of the renal artery. The arteriographic appearance was that of a severely stenosing lesion with regions of intense stenosis alternating with regions of lesser narrowing. This lesion has also been called “fibromuscular hyperplasia” because the variably severe stenosis produces an irregular arterial outline that suggests “beading.” This study shows subadventitial fibroplasia to be distinct from fibromuscular hyperplasia, as well as from medial fibroplasia, which produces the “string-of-beads” arteriogram.

Angiomatous lymphoid hamartoma. Report of five cases with a review of the literature

Five new cases of angiomatous lymphoid hamartoma (synonym: lymph node hyperplasia, Castleman, 1954) are reported, and 57 cases from the literature are reviewed. Three of the 5 intrathoracic tumors showed clinicopathologic characteristics comparable with those described in the literature. These included: (1) a nonspecific clinical presentation; (2) microscopic features consisting of normal or abnormal lymphoid follicles and an interfollicular stroma that contained numerous blood vessels and lymphocytes; and (3) a benign course after surgical excision. The 2 cases of tumor in the retroperitoneum are the first to be reported to occur in this site and were significant in that both roentgenographically resembled malignant tumors. Morphologic studies of the tumors suggest that angiomatous lymphoid hamartoma represents a vascular hamartoma occurring in a lymph node; and that the abnormal follicles are the result of distortion by proliferating blood vessels abutting previously normal lymphatic follicles.

Renal trauma and hypertension

Eleven cases of hypertension after renal trauma were reviewed. The average age of the patients was 22 years on first examination at the Cleveland Clinic. Ten patients were asymptomatic; 4 were not aware that they had suffered specific renal trauma. The onset of hypertension occurred at very different intervals after the traumatic event, sometimes after several years, thus making imperative long-term observation of patients suspected of having sustained renal trauma. Nephrectomy ameliorated hypertension in 7 of 8 patients, 6 of whom became normotensive; more conservative operations failed to relieve hypertension in 2 of 3 patients. Mechanisms of post-traumatic renal hypertension include parenchymal compression from hematomas (analogous to the cellophane-wrapped kidney of Page) and renal artery stenosis or occlusion (analogous to the Goldblatt kidney).

Differential renal venous renin activity in diagnosis of renovascular hypertension. Review of 29 cases.

Bilateral renal venous renin activity determinations were performed preoperatively in 29 patients with unilateral renal artery disease. After the operations, 19 patients had relief of hypertension and 10 did not. Analysis of the renal venous renin activity data indicated that a value for renin activity (stenotic side) greater or less than 4 ng/ml per 4 hours or renin activity ratio stenotic(S)/nonstenotic(N) greater or less than 1.5 yielded a correct prediction of surgical results in 79 percent and 72 percent of the cases, respectively. The renin activity (stenotic side) greater than 4 ng/ml per 4 hour and renin activity ratio S/N greater than 1.5 combined, as an index of surgical success, yielded a correct prediction in 69 percent of the cases. However, when the renin activity (stenotic side) and renin activity ratio S/N were both increased (indicative of success in 12 of 14 patients) or were both normal (indicative of failure in all 5 patients with this finding) the prognostic index was high (89 percent). When there was a disparity in the two values (as in 10 patients), the prognostic accuracy was uncertain and results unpredictable. The criteria of other investigators for a positive renal venous renin study were reviewed. Reanalysis of these data indicated that the criteria of success as denoted by renin activity ratio S/N greater than 1.5 and elevated renal venous renin activity (stenotic side) compare favorably with those obtained with a ratio of 2.0 or more and elevated renal venous renin activity (stenotic side) in the series reviewed.

Chronic glomerular microangiopathy and metastatic carcinoma.

Two patients with metastatic colonic adenocarcinoma developed deterioration of renal function six and nine months after the diagnosis of malignant disease. A renal biopsy specimen in one case and both postmortem specimens revealed thickening of glomerular capillary loops with focal reduplication of basement membrane-like material. Ultrastructural examination of all three specimens demonstrated a lucent subendothelial zone and no evidence of electron dense deposits. Antifibrinogen staining outlined most capillary loops in one case. It appears that chronic intravascular coagulation induced by the neoplasm was the major pathogenetic process involved in the production of the glomerular lesion in each case.

Role of conization in the detection and treatment of cervical carcinoma in situ

Abstract A study comprising 259 cases of cervical carcinoma in situ has been presented. One hundred and seventy-one patients are being followed after radical conization as the only therapy administered; data on 62 patients who have undergone a second operation (hysterectomy or cervicectomy) have been analyzed. The methods of detection, conization, cytologic preparation and interpretation, along with intensive cytologic follow-up have been outlined. It is our opinion, based upon the data presented in this study, that the vast majority of patients with carcinoma in situ of the uterine cervix can be safely treated through radical conization without regard to the patients age, parity, or desire for pregnancy.

Hyperinsulinism due to islet-cell tumors simulating sarcoma: a report of two cases of large tumors composed of round and spindle cells associated with hypoglycemia.

Functioning islet-cell tumors are usually composed of nests, cords, or sheets of cells, resembling beta cells and associated with varying amounts of intercellular stroma. Such tumors are usually small. In contrast, we have observed two very large neoplasms which caused hypoglycemia and were composed predominantly of spindleshaped cells with cytoplasmic processes. Associated with these spindle cells in both of the tumors were round cells without cytoplasmic processes. The purpose of this paper h to describe the clinical features and pathologic findings of these two cases in order to substantiate the thesis that these tumors are actually functioning isletcell neoplasms.

FURTHER OBSERVATIONS ON THE EFFECT OF DIMETHYL SULFOXIDE IN PATIENTS WITH GENERALIZED SCLERODERMA (PROGRESSIVE SYSTEMIC SCLEROSIS)

Systemic scleroderma (progressive systemic sclerosis) is a connective tissue disorder of unknown etiology. According to Talbott,’ the disease is ultimately fatal, although duration of life following onset of symptoms is extremely variable and unpredictable in most patients. Varying degrees of cutaneous and subcutaneous involvement of the hands, forearms or face are generally observed. Raynaud’s phenomenon occurs almost consistently and subsequently, ischemic ulcers may appear a t the fingertips, elbows or ankles. As the disease progresses, all systems of the body may be affected. Eventually, disabling changes in skin, muscles and joints may be associated with circumscribed or interstitial calcinosis. Pathologic changes involving the connective tissue have not been clearly defined and opinions vary regarding the abnormal changes that occur. Some investigators report that there are no abnormalities in the collagen or amorphous ground s u b ~ t a n c e . ~ ’ ~ Others believe that amorphous material is inwhile still others say that the collagen fibers are increased.6 Various other studies have suggested that there are biochemical abnormalities within the connective tissue, i.e., depolymerized ground substance and increased cutaneous hexosamine. Numerous therapeutic measures, including corticosteroids, sodium endrate, reserpine, serotonin inhibitors, potassium aminobenzoate, chloroquine and cytotoxins have been used, but none is consistently or highly effective, The dismal outlook regarding treatment of this disease is reflected in an editorial comment in the Sixteenth Rheumatism Review, which states, “We doubt the efficacy of any therapy for systemic scler~sis .”~ 7