Mary L. Ostrowski

Tall cell variant of papillary thyroid carcinoma: a reassessment and immunohistochemical study with comparison to the usual type of papillary carcinoma of the thyroid.

A review of 92 consecutive cases of papillary thyroid carcinoma diagnosed at The Methodist Hospital revealed 11 tall cell variant (TCV) cases in nine women and two men. There was a greater average age and larger tumor diameter of TCV cases compared with papillary thyroid carcinoma of the usual type (UPTC), but these differences were not statistically significant. Extrathyroidal extension of tumor was noted in nine of 11 TCV cases and was intraoperatively evident in five cases. The presence of extrathyroidal extension represented a statistically significant difference between TCV and UPTC (p = 0.0001) in a multivariate stepwise logistic regression analysis, with controls for variables of age, sex, tumor size, and lymph node metastases. In 11 TCV patients, tumor recurrence was present in two cases, and there was one tumor-associated death with 1 to 4 years of follow-up. Immunohistochemical stains for thyroglobulin, vimentin, keratins, and Leu-7 were positive in all TCV cases and in 16 of 16 UPTC. Immunoreactivity with antibodies to Leu M1 antigen, a myelomonocytic marker included in cluster designation group (CD 15), which is present in many adenocarcinomas, was present diffusely in all TCV, in contrast to UPTC (with sparse immunostaining in only one of 16 cases). Immunoreactivity with antibodies to ZC-23, an anti-carcinoembryonic antigen (CEA) monoclonal antibody with cross-reactivity to nonspecific cross-reacting antigen and biliary glycoprotein antigen, was present in all TCV but was not present in UPTC. COL-1, a CEA-specific monoclonal antibody, was nonimmunoreactive with all TCV and UPTC cases. Epithelial membrane antigen (EMA) was present in all TCV but was also present focally in eight of 16 UPTC, sometimes in a membranous pattern in epithelium surrounding cystic or hemorrhagic spaces. Strong immunoreactivity with antibodies to Leu M1 and EMA in papillary carcinomas of the thyroid has been associated with advanced stages of disease and tumor-associated mortality. The pattern of immunoreactivity in TCV is dissimilar to that in UPTC and is supportive evidence that TCV is a neoplasm that is distinct from papillary thyroid carcinoma of the usual type.

Lesions of the bones of the hands and feet

Neoplasms and their simulators in the bones of the hands and feet include the majority of those found in other skeletal sites, and a disproportionate number of some. We examined the clinical, radiologic, and pathologic features of 240 lesions of the hand and foot bones. Benign tumors and lesions including reactive and reparative conditions comprised 203 cases. The largest single category of neoplasms was that with cartilaginous differentiation, with enchondromas (29 cases) and chondrosarcomas (15 cases) the most common. Noncartilaginous malignant tumors were infrequent and displayed typical radiologic and pathologic features. Florid reactive periostitis, bizarre parosteal osteochondromatous proliferations, and giant cell reparative granulomas made up a larger percentage of lesions in these locations than in other skeletal sites. Lesions of the bones of the hands and feet may frequently be biopsied or treated at hospitals without large orthopedic tumor services. Thus, it is important for the surgical pathologist to be aware of the frequency and characteristics of lesions which may present in these sites.

Primary Repair Without Augmentation for Early Neglected Achilles Tendon Ruptures in the Recreational Athlete

From 1987 to 1994, the senior author performed 41 Achilles tendon repairs. We identified 11 patients during this period (age, 35.3 years; range, 26–60 years) who fit the criterion for neglected Achilles tendon rupture (repair ≥ 4 weeks and ≤ 12 weeks from injury). All patients underwent proximal release of the gastrocsoleus complex, imbrication of the early fibrous scar without excision of any local tissue, and primary repair of the tendinous ends with two No. 5 Ticron sutures (5R, 6L). Several (three to five) No. 0 Vicryl sutures were used to augment the repair. The ankle was placed in a 20° plantarflexion nonweightbearing short leg cast for 3 weeks. All skin closures were primary. At 3 weeks, weightbearing as tolerated was initiated in a short leg cast. The cast was discontinued at 6 weeks, and physical therapy was initiated, consisting of range of motion exercises and closed kinetic exercises, progressing to functional exercises as swelling, strength, and pain allowed. Minimal follow-up was 18 months (mean, 3.5 years; range, 1.5–5.8 years). There have been no subsequent ruptures to date. All patients returned to a preinjury level of activity at a mean of 5.8 months (range, 2.5–9 months). Total range of motion was not different (P > 0.05) between the involved (67°) and uninvolved (74°) ankle. Plantarflexion loss of strength in the involved ankle was the same (98.4%, 88.1%, and 87.6% respectively, involved to uninvolved) as that seen after acute repair at all speeds tested. Visual analog pain scale (0 to 10) revealed a mean score of 0.7 (range, 0–2) during activities of daily living and 1.0 (range, 0–3) during sports activity. The subjective and objective outcome was similar (P > 0.05) to that seen after an acute repair by the same surgeon. There were no complications including skin sloughs or nerve damage. We believe this is the first article to report the results after primary repair without augmentation for the neglected Achilles tendon rupture. We conclude that this approach can result in excellent clinical and functional outcome, a low rate of subsequent rupture, and a high rate of return to sports in the recreational athlete whose repair is performed between 4 and 12 weeks after injury.

Cell proliferation in the growing human heart: MIB-1 immunostaining in preterm and term infants at autopsy

Few studies of human cardiac myocyte proliferation in the perinatal period have been conducted. We measured the proliferative activity of left ventricular myocytes in tissue obtained at autopsy in three surgically induced abortuses, 20 preterm infants with gestational ages ranging from 12 to 35 weeks, eight term infants with ages ranging from 1 day to 11 months, and five adults. The preterm infants lived less than 24 h, thus simulating the in utero condition of developing hearts. To assess the proliferative activity of the myocytes, we measured immunoreactivity using the monoclonal antibody MIB-1 against the recombinant Ki-67 nuclear antigen. Immunostained sections were examined by light microscopy, and the results expressed as a staining index (SI) of 0-3, according to the percentage of positively stained myocyte nuclei. Myocyte proliferative activity remained constant during the early preterm period and decreased in the late preterm and early postterm periods. Adult myocytes, regardless of cardiac weight, did not reveal proliferative activity as assessed by immunostaining. This proliferation pattern is consistent with findings in most earlier studies in animal models.

Oncocytic mucoepidermoid carcinoma of the salivary glands.

Two parotid mucoepidermoid carcinomas with predominant oncocytic features were initially assessed on frozen section. Because of extensive oncocytic change, it was inferred that the lesions were most likely benign. Permanent sections revealed low-grade mucoepidermoid carcinoma with prominent oncocytic change (in more than 75% of the neoplasms) in both cases. Review of 48 additional consecutive cases of mucoepidermoid carcinoma of the salivary glands revealed prominent oncocytic change (accounting for 60% of the neoplasm) in one high-grade lesion. Phosphotungstic acid-hematoxylin stains revealed strong granular cytoplasmic staining in the oncocytic elements; immunohistochemical stains for antimitochondrial antibodies also showed intense immunoreactivity in these cells. Oncocytic change is not typically a prominent feature of mucoepidermoid carcinoma of the salivary glands, and to our knowledge, only three such cases have been reported previously. Because most salivary gland lesions with oncocytic change are benign, it is important to distinguish mucoepidermoid carcinoma from other entities that may show prominent oncocytic change. We report three additional examples of this rare lesion, two low-grade tumors and one high-grade tumor, and review our experience with oncocytic change in mucoepidermoid carcinoma of the salivary glands.

Paraganglia of the prostate. Location, frequency, and differentiation from prostatic adenocarcinoma.

In contrast to paraganglia of the urinary bladder, prostatic paraganglia have been largely unreported. Following the discovery of paraganglia in two separate radical prostatectomy specimens, we reviewed 100 randomly selected radical prostatectomy specimens to document the location and frequency of prostatic paraganglia. Twelve additional paraganglia were identified in eight resections, for a total of 14 paraganglia in 10 cases. Most paraganglia were located in or adjacent to lateral neurovascular bundles and, rarely, in lateral prostatic stroma. The size of paraganglia ranged from 0.1 to 1.7 mm (median 0.9 mm). Paraganglia consisted of clusters of cells in patterns that ranged from lobular to diffuse, usually with a prominent stromal vascular component. The cells contained bland oval nuclei and clear cytoplasm, which was often abundant. Occasionally, larger cells with larger nuclei were present. Immunohistochemical stains for chromogranin, neuron-specific enolase, and synaptophysin were positive; those for prostatic-specific antigen were uniformly negative. In one of our cases, histologic similarity was noted between a paraganglion and an adjacent prostatic adenocarcinoma with a “hypernephroid” pattern. Recognition of prostatic paraganglia, with appropriate immunohistochemical stains when necessary, will obviate the possibility of confusing these structures with prostatic adenocarcinoma.

Intraosseous Innervation of the Human Patella A Histologic Study

Background The soft tissue structures surrounding the human knee joint have been the subject of extensive anatomic study. The detailed histologic findings within the bone of the human patella, however, have not been systematically studied. While the nerves supplied to the periarticular soft tissues have been very well documented, the nerves supplied to the interior of the bony patella have never been described. Hypothesis This study tests the hypothesis that the patella contains an intraosseous nerve network. Further, the authors investigate the anatomic location of these intraosseous nerves to better understand their possible clinical relevance. Study Design Descriptive laboratory study. Methods Ten matched pairs of cadaveric patellae (left and right patellae from the same individual; 20 total) were prepared for evaluation by hematoxylin and eosin staining using a technique that allows the creation of complete, large histologic sections of individual patellae. The matched specimens were dissected free of soft tissue and then sectioned using a diamond-wafering saw into 3-mm sagittal (left patella) and transverse (right patella) sections. Sections were then decalcified and whole-mounted into paraffin blocks for further sectioning using a large-format microtome. All 20 specimens were prepared for evaluation. Age at death averaged 80 years (range, 64-91). All specimens demonstrated at least grade II chondromalacia. Results Nineteen of 20 (95%) specimens demonstrated intraosseous nerves. Of 248 sections studied, 116 (47%) demonstrated intraosseous nerves, with 227 individual nerves identified. The density of intraosseous nerves was greatest in the medial and central portions of the patella, with a significant paucity identified laterally. Conclusion The primary intraosseous innervation of the patella derives from a medially based neurovascular bundle. Clinical Relevance A better understanding of the nerves within the human bony patella may improve understanding the patho-physiology of anterior knee pain syndromes.

Cryptococcal osteomyelitis. Report of a case with aspiration biopsy of a humeral lesion with radiologic features of malignancy.

BACKGROUND Osteomyelitis due to Cryptococcus neoformans typically exhibits lytic lesions on radiographs. Extensive periosteal reaction is an uncommon feature. CASE A 68-year-old man presented with pain and swelling in the left elbow. Radiologic studies exhibited a lytic humeral lesion with extensive periosteal reaction, interpreted as a malignant neoplasm. Fine needle aspiration biopsy (FNA) revealed abundant cryptococcal organisms. CONCLUSION Cryptococcus is an uncommon cause of lytic osseous lesions that may mimic malignant neoplasms. Extensive periosteal reaction may support a radiologic diagnosis of primary osseous malignancy in rare cases. FNA with examination of Diff-Quik-stained slides may be employed for distinguishing cryptococcal osteomyelitis from malignant tumors and for prompt identification of the organisms.

Giant cell reparative granuloma of the orbit associated with cherubism.

PURPOSE To report a case of cherubism with extensive, bilateral orbital involvement occurring in a 27-year-old woman who had the diagnosis established at the age of 4 years. DESIGN Single interventional case report. INTERVENTION Ophthalmologic examination and computed tomography were performed. The patient underwent multiple surgical excisions using a bicoronal and transorbital approach. The excised orbital tissues were studied histopathologically. RESULTS Computed tomography showed bilateral inferior lateral masses involving the orbital floors and producing marked superior displacement of the orbital contents. The intrinsic expansile bone lesions involved the inferior and lateral orbital walls with apical compression of the optic nerves. Histopathologic examination of the masses revealed scattered giant cells in a fibroblastic stroma containing small vascular channels. The lesion was interpreted as giant cell reparative granuloma. CONCLUSIONS Giant cell reparative granuloma is an uncommon bone lesion that might involve the orbit. Cherubism should be included in the differential diagnosis of lesions that show the histopathologic features of giant cell reparative granuloma.

Aspiration Biopsy of Osseous Metastasis of Retroperitoneal Paraganglioma

BACKGROUND Paragangliomas are uncommon tumors, only 10% of which are malignant, as evidenced by metastatic disease. It is rare for paraganglioma to present with symptomatic osseous metastases. CASE A retroperitoneal paraganglioma presented in a 52-year-old man as painful metastases in the rib and vertebrae. Fine needle aspiration (FNA) of a lumbar vertebral lesion showed cells arranged singly and in loose clusters with fragile, vacuolated or finely granular cytoplasm, marked anisonucleosis and mitoses. Rare zellballen-type structures and intranuclear inclusions were present. Immunohistochemical studies of a subsequent FNA core biopsy of the retroperitoneal mass showed strong immunoreactivity with chromogranin and negative staining for keratin; that was helpful in differentiating this tumor from others in the differential diagnosis. CONCLUSION The cytologic diagnosis of paraganglioma is difficult as these tumors exhibit a plethora of features that overlap those of many other neoplasms. The diagnosis can be confirmed with appropriate immunohistochemical studies of corresponding core biopsies.