Neelam B. Kumar

Histopathology differentiates acute self-limited colitis from ulcerative colitis

Acute self-limited colitis (ASLC) must be distinguished from chronic ulcerative colitis (CUC) for the proper early management of patients with the acute onset of bloody diarrhea. This study was undertaken to determine if any clinical, endoscopic, microbiologic, or histologic parameters can be used to make this distinction reliably and quickly. Forty-eight patients with ASLC, 36 patients with chronic ulcerative colitis during their first attack [CUC(F)], and 84 patients with recurrent flares of chronic ulcerative colitis [CUC(R)] were studied prospectively. The presence of fever (temperature greater than 100 degrees F), abdominal pain, or the time from onset of bloody diarrhea to presentation were not discriminatory. Overall clinical and endoscopic severity were identical among the three groups. Microbiologic studies identified an infectious agent in only 42% of patients with ASLC. Histopathologic features always distinguished patients with CUC from those with ASLC. No case of ASLC was misdiagnosed histologically as CUC or vice versa. Plasmacytosis in the lamina propria extending to the mucosal base and mucosal distortion were present in all cases of CUC(F) and CUC(R), but were absent in all cases of ASLC. The finding of focal cryptitis during the resolving phase of ASLC could be confused with similar lesions in biopsy specimens from patients with Crohns disease and mandates clinical follow-up. Histopathology is thus the only reliable diagnostic tool for the rapid differentiation of ASLC from CUC. However, biopsy specimens are only diagnostic when obtained during the acute phase of illness; that is, usually within the first 4 days from the onset of symptoms.

The histopathologic spectrum of acute self-limited colitis (acute infectious-type colitis)

Acute self-limited colitis (ASLC) is a self-limiting diarrheal illness which is often caused by known infectious agents (Campylobacter, Salmonella, and Shigella), but many cases are of unknown etiology. This report describes the histopathologic features of acute self-limited colitis as related to its natural history. The extent of inflammation and regeneration varies with the duration of the disease. In the peak activity stage (within 0–4 days of onset of bloody diarrhea) there is mucosal edema, cryptitis, crypt ulcers, and abcesses. At the time of resolution (within 6–9 days of onset of bloody diarrhea), regenerative features become apparent along with residual focal neutrophilic cryptitis. In the later stages of resolution, along with some regenerative features, occasional crypts with transmigrating lymphocytes may be present.A rectal biopsy is diagnostic only in the early stages of the disease. Later in the course, the rectal biopsy from patients with ASLC may be nondiagnostic or may be confused with Crohns disease due to the persistence of focal cryptitis. In our experience, the presence of crypt distortion and basal plasmacytosis are the two most useful criteria to differentiate chronic ulcerative colitis from ASLC.

Carcinoma of the vagina. Factors influencing treatment outcome

A 33‐year review from the University of Michigan Medical Center of 86 cases of primary carcinoma of the vagina included 68 squamous carcinomas, 13 adenocarcinomas, and 5 small cell carcinomas. There was a 26% incidence of prior cervical carcinoma and a 21% incidence of prior pelvic radiation therapy. The median interval between the diagnosis of invasive cervical and vaginal carcinoma was 20 years. Survival was strongly correlated with stage. There was no association between survival and involvement of a particular vaginal segment or the amount of vaginal surface area involved with tumor. Irradiation was the most frequently employed primary therapy for vaginal carcinoma. Local control was correlated with the mid‐tumor irradiation dose, with predictable control obtained only with doses above 7500 rad. The use of interstitial therapy should facilitate local control without increasing the complication rate.

Autopsy findings in patients with uterine sarcoma

Autopsy findings were reviewed in 22 patients treated for uterine sarcoma at the University of Michigan Hospitals. Included are 11 mixed mesodermal tumors, 6 endometrial stromal sarcomas, and 5 leiomyosarcomas. Only one patient died with disease limited to the pelvis. Forty-five percent of the patients died with disease limited to the pelvis and abdomen. The most common site of the disease above the diaphragm was the lung. Lymph nodes were involved in 59% of our patients. There were no obvious differences in the patterns of spread between the tumor types.

Prognostic features of vulvar melanoma: a clinicopathologic analysis.

: We studied 19 cases of vulvar melanoma to determine significant clinical and histologic prognostic predictors. The average follow-up time was 32 months. Fourteen patients died of melanoma, four patients are alive with no evidence of melanoma, and one patient is alive with residual melanoma. All disease-free survivors had clinical stage I disease and a maximum tumor thickness of 1.3 mm. The average mitotic count in this group was 5.5 per 10 high power fields (HPF) and 50% of the tumors were superficial spreading melanomas. All survivors were treated by radical vulvectomy with bilateral inguinal lymph node dissection. Of the nonsurvivors, four (28.5%) were clinical stage I, five (36%) were clinical stage II, four (28.5%) were clinical stage III, and one (7%) was clinical stage IV. The average tumor thickness for nonsurvivors was 9.5 mm (range 2.6-18 mm) and the average mitotic count was 13.3/10 HPF. Only three (21%) tumors from nonsurvivors were superficial spreading melanomas; the majority were nodular melanomas. The statistically significant prognostic predictors were clinical stage of disease and tumor thickness. Tumor type (i.e., superficial spreading, nodular, or acral lentiginous) correlated with tumor thickness and was indirectly related to prognosis. The mitotic count was also a useful prognostic feature.

Microinvasive carcinoma of the vagina: A distinct clinical entity?

Six patients with superficially invasive squamous carcinoma of the vagina are described. All had less than 2.5 mm of invasion as measured from the surface, lacked involvement of the lymph-vascular spaces, and arose within a field of carcinoma in situ. Three of the six had previously been treated for carcinoma of the cervix. The patients with microinvasive carcinoma had a median age 10 years younger than that of patients with Stage I carcinoma of the vagina. Treatment of the six patients has been by partial or total vaginectomy. With follow-up of 51 to 172 months, there have been no recurrences. More experience is needed to define microinvasive squamous carcinoma of the vagina and to determine the optimal treatment for these lesions.

The prognostic significance of tumor emboli in lymphatic or vascular spaces of the cervical stroma in Stage IB squamous cell carcinoma of the cervix

The presence of tumor emboli in lymphatic or vascular spaces within the cervical stroma in squamous cell carcinoma of the cervix has been reported by several authors to be associated with a decrease in 5-year survival. In a 10-year review of 124 radical hysterectomies for Stage IB squamous cell carcinoma of the cervix at the University of Michigan from 1970 to 1980 the presence of tumor emboli in the cervical stroma without other known risk factors did not significantly alter the 3- and 5-year survival. With the potential risks and lack of proved benefit the use of adjuvant radiotherapy or chemotherapy in this setting is not recommended.

Quantification of IgG-Containing Plasma Cells as an Adjunct to Histopathology in Distinguishing Acute Self-Limited Colitis from Active Idiopathic Inflammatory Bowel Disease

ASLC is clinically and endoscopically similar to active idiopathic IBD, especially ulcerative colitis. While several histopathologic criteria have been described which are useful in distinguishing these conditions, the diagnosis can still be difficult. In this study, we review the use of immunofluorescence on formalin-fixed paraffin-embedded biopsies from patients with ASLC. While tissues from active IBD have a striking increase in the number of IgG- and a lesser increase in the IgA- and IgM-containing plasma cells in the lamina propria, tissues from ASLC have normal numbers of IgG-containing cells with only a slight increase in IgA- and IgM-containing cells. The use of immunofluorescence on these tissues can provide quantifiable information which may be a helpful diagnostic adjunct in distinguishing these alternatives if histopathologic evaluation is equivocal.

Prognostic features of carcinoma of the fallopian tube

One hundred fifteen women with carcinoma of the fallopian tube were examined in this retrospective review. A third of the patients were nulliparous and 37% had evidence of old pelvic inflammatory disease. The most common symptoms were bleeding, pain, and/or vaginal discharge. Prognostic factors that predicted death from tumor were the presence of extratubal disease at initial surgery and the bulk of residual tumor left after the initial surgery. With disease limited to the fallopian tube, the depth of invasion of the tubal wall was correlated with the risk of treatment failure. Among patients with disease limited to their fallopian tubes, there was no statistically significant improvement in survival with the addition of either pelvic irradiation or single-agent chemotherapy. Among women with extrapelvic disease, survival improved significantly with the use of cis-platinum- containing multiagent chemotherapy.

Prognostic Features of Vulvar Melanoma: A Clinicopathologic Analysis

We studied 19 cases of vulvar melanoma to determine significant clinical and histologic prognostic predictors. The average follow-up time was 32 months. Fourteen patients died of melanoma, four patients are alive with no evidence of melanoma, and one patient is alive with residual melanoma. All disease-free survivors had clinical stage I disease and a maximum tumor thickness of 1.3 mm. The average mitotic count in this group was 5.5 per 10 high power fields (HPF) and 50% of the tumors were superficial spreading melanomas. All survivors were treated by radical vulvectomy with bilateral inguinal lymph node dissection. Of the nonsurvivors, four (28.5%) were clinical stage I, five (36%) were clinical stage II, four (28.5%) were clinical stage III, and one (7%) was clinical stage IV. The average tumor thickness for nonsurvivors was 9.5 mm (range 2.6-18 mm) and the average mitotic count was 13.3/10 HPF. Only three (21%) tumors from nonsurvivors were superficial spreading melanomas; the majority were nodular melanomas. The statistically significant prognostic predictors were clinical stage of disease and tumor thickness. Tumor type (i.e., superficial spreading, nodular, or acral lentiginous) correlated with tumor thickness and was indirectly related to prognosis. The mitotic count was also a useful prognostic feature.