Intraoperative Histological Examination Research Articles

Nephron-sparing procedures in 11 patients with Wilms' tumor.

In unilateral Wilms' tumor (WT), tumor nephrectomy is the standard surgical approach, whereas partial nephrectomy (PN) is controversially discussed. The aim of our retrospective study was to show that in selected cases of unilateral WT kidney-sparing operations could be a reasonable alternative to nephrectomy and to discuss the results of patients with bilateral WT treated by tumor enucleation. From 1981 to 1998, seven patients with unilateral nephroblastoma (four stage I, one stage III and two stage IV) had tumor resection by PN (five right side, two left side), which was planned when the tumor volume was reduced after 4 to 6 weeks of chemotherapy by at least 50%, when the tumor occupied one pole or was easily resectable, when 50% or more of the kidney tissue remained and when paraaortic lymph nodes were free by intraoperative histological examination. In four patients with bilateral WT (stage V) bilateral tumor enucleation was carried out-except in one patient in whom the contralateral kidney had to been removed because of extension of the tumor via the inferior vena cava to the right atrium. All patients ( n = 11) received pre- and postoperative chemotherapy followed by radiotherapy in four patients. All patients with unilateral WT ( n = 7) are still alive and disease free (follow-up time: mean 6.6 years, range: 28 months to 11 years) with normal renal function, although two patients with secondary nephrectomy revealed creatinine clearance levels at the lower range. In six patients primary PN was performed successfully. In a stage III tumor patient (intraperitoneal metastasis, free lymph nodes), secondary nephrectomy was necessary due to renal arterial thrombosis 2 days after PN. In one stage IV tumor patient (lung metastasis, free lymph nodes), the primary resection was not far enough away from the tumor margin so that an additional slice of tissue with then tumor-free margins had to be resected. This patient evolved a local relapse 19 months after PN and had to be nephrectomised thereafter. In the group of bilateral WT patients ( n = 4), one child died 2 months after surgery during chemotherapy because of central venous line sepsis. One patient who additionally suffered from inferior vena cava tumor thrombosis extending to the right atrium making nephrectomy of the right kidney necessary developed chronic renal failure 4.7 years postoperatively. The other two stage V tumor patients have creatinine clearance levels within the normal range. Kidney-sparing procedures remain the operative approach of choice in patients with bilateral WT, but bear the risk of chronic renal failure when one kidney has to be removed. PN in children with unilateral WT, carried out by an experienced surgeon, is a reasonable alternative to nephrectomy if strict guidelines such as excellent tumor response to preoperative chemotherapy and easy resectability far away from the tumor margins through healthy kidney tissue are followed. Paraaortic lymph nodes must be free of tumor invasion in order to avoid local radiotherapy. PN prevents the patient from having to have dialysis in cases of contralateral nephrectomy resulting from metachronous WT or subsequent renal trauma.

Extragnathic fibromyxoma of the calcaneum: report of a case

Fibromyxoma of the bone occurs mainly in the facial bones and it has not been previously reported in the calcaneum. We present a rare case of extragnathic fibromyxoma affecting the calcaneum in an adult male patient who complained of persistent heel pain. Intraoperative characteristics and histological examinations of the lesion demonstrated fibromyxoma. Open curettage, local application of 5% phenol and filling the cavity with bone cement relieved the patient's symptoms, with no recurrence. This case represents another type of the benign lesions affecting the calcaneum.

乳腺原発腺様嚢胞癌の１例

We report a case of adenoid cystic carcinoma of the breast. A 48-year-old female presented with a solid mass with a cystic region measuring 1.7×1.5 cm in the left breast. The radiological differential diagnosis included phylloides tumor, fibroadenoma, and carcinoma. Intraoperative histological frozen section examination did not reveal any typical features of adenoid cystic carcinoma. Imprint smears from the breast tumor showed many spherical clusters predominantly composed of small round cells with finely granular chromatin, suggestive of myoepithelial cells, and also cells with relatively large nuclei, suggestive of epithelial cells.

Laparoscopic cholecystectomy and gallbladder cancer.

This study was designed to assess the treatment of patients in whom gallbladder cancer was diagnosed in the course of histological examination of their gallbladders, which were removed during laparoscopic cholecystectomy. Six (0.29%) cancers were found among 2,017 patients who underwent laparoscopic cholecystectomy. Four of these cancers (0.22%) were in 1,831 gallbladders with normal walls, two (1.0%) were in 186 with thicker walls, and two (1.8%) were in 109 patients in whom conversion was necessary because of extensive inflammation and thickening of gallbladder wall. In two cases, the cancer did not cross the muscular layer. In one of them, no further treatment was undertaken. In the second case, liver resection and lymphadenectomy was performed. In the other four cases, dissemination was diagnosed during laparotomy, precluding radical treatment. Thickened and infiltrated gallbladder walls in patients without preoperative symptoms of cholecystitis should raise a suspicion of cancer. The surgeon should be prepared to perform a conversion, an intraoperative histological examination, and an appropriate radical operation, if necessary.

Limitation of cholangiography in assessing longitudinal spread of extrahepatic bile duct carcinoma to the hepatic side.

Preoperative assessment of longitudinal spread of bile duct carcinoma (BDC) to the hepatic side remains a difficult problem for diagnostic imaging. We studied the accuracy of cholangiography in assessing BDC. In 54 patients with extrahepatic bile duct cancer, cholangiographic findings were compared retrospectively with the histological findings of the resected specimens. Histological examination of specimens indicated longitudinal spread of the tumour to the hepatic side in 22 of 54 patients. The accuracy of cholangiography in assessing the extent of the longitudinal spread was only 34/54 (63%). When the cholangiographic images showed a main tumour with a collapsed edge, there was a significantly higher frequency of longitudinal spread compared with tumours with sharp edges (P< 0.05). In contrast, the accuracy of mapping biopsy under percutaneous transhepatic cholangioscopy (n=24) was 83%. Cholangiography cannot accurately assess the extent of the longitudinal spread of bile duct cancer. When cholangiographic images show a tumour with a collapsed edge, preoperative or intraoperative histological examination is essential to determine a suitable surgical line.

Resection and graft repair for localized hypertrophic neuropathy.

Formulation of surgical management recommendations for localized hypertrophic mononeuropathy has been difficult because of the infrequency of the lesion, lack of precise pathological diagnosis, and uncertainties regarding its cause. The purpose of this retrospective review of the Louisiana State University (LSU) experience with this unusual neuropathy was to evaluate the efficacy of lesion resection and interposition grafting in its management. The charts of 15 patients operated on at LSU during a 15-year period with a pathological diagnosis of localized hypertrophic neuropathy were reviewed. Hypertrophic lesions were located on major named peripheral nerves of the extremities, distributed equally to the upper and lower extremities. Family history was negative for all patients, and entrapment or trauma, other than previous surgery, were unlikely by symptom location or history. Weakness was the most common presentation. The mean length of symptoms was 76 months. Atrophy, sensory loss, Tinel's sign, focal tenderness, and a mass were found in the majority of patients. Preoperative electrophysiological studies showed chronic denervational changes in all patients. At surgery, if no action potential or one of low amplitude was recorded across the lesion, the lesion was resected and an autologous nerve graft measuring from 3.5 to 8.5 cm in length was interposed. During follow-up periods of 1 or more years, seven of nine patients with localized hypertrophic mononeuropathy treated with graft repairs were either unchanged or improved. Localized hypertrophic mononeuropathy is a progressive process associated with pathological nerve changes that correlate with eventual severe functional loss. If intraoperative histological examination shows onion bulb neuropathy and intraoperative nerve action potentials confirm a nonfunctioning or poorly functioning segment, lesion resection with interposition graft repair provides the possibility of some degree of recovery.

Primary Non-Hodgkin's Lymphoma of the Breast: A Report of Two Cases.

BACKGROUND: Primary non-Hodgkin's lymphoma of the breast (PBNHL) is a rare neoplasm and PBNHL occuring in a man is extremely rare. METHODS: We report herein two cases of PBNHL and discuss methods of diagnosis and treatment. RESULTS: The first patient was a 35-year-old woman who presented with an elastic-hard mass in her left breast and adenopathy in her left axillary fossa. Mammography and ultrasonography suggested left breast cancer. Frozen sections demonstrated PBNHL histologically. Quadrantectomy of the breast was performed followed by chemotherapy. The second patient was a 65-year-old man with an elastic-hard mass in his left breast and left axillary lymphadenopathy. Mammography and ultrasonography suggested breast cancer or a soft tissue tumor. Intraoperative histological examination revealed a diagnosis of non-Hodgkin's lymphoma (NHL). A simple mastectomy and postoperative chemotherapy were performed and the patient had a good prognosis. CONCLUSION: A multidisciplinary approach including surgery, chemotherapy, andradiotherapy is indispensable in treating PBNHL, after diagnosis by excisional biopsy or aspiration cytology.

Leiomyomatosis peritonealis disseminata associated with endometriosis: a case report and literature review

Leiomyomatosis peritonealis disseminata (LPD) is a rare disease characterised by the presence of multiple smooth muscle tumour nodules throughout the peritoneal cavity. Approximately 50 cases of LPD have been reported to date in the world literature. There is a very high association with excess exogenous and endogenous female gonadal steroids, specifically oestrogen and progesterone. LPD has been described almost only in premenopausal women and is mostly asymptomatic. Four cases of malignant transformation of this disease have been reported. We report a case of a patient with prolonged exposure to oral contraceptives, operated because of hypermenorrhea and `myoma in statu nascendi'. A metastasing myomatous tumour was suspected during the operation. LPD was diagnosed by intraoperative histological examination. Abdominal hysterectomy was performed. Five months later a second laparotomy had to be done because of an ovarian endometriosis tumour of about 10 cm size. A bilateral salpingo-oophorectomy and omentectomy were performed.

Benign tumors of the lung: a 20-year surgical experience.

In the following report, we describe our investigation of the diagnosis and operative methods for benign tumors of the lung, in which the surgical treatment was selected due to suspicious malignancy. This study included 22 patients with benign tumors. The patients' mean age was 55 years old. The histological diagnosis was made postoperatively prior to 1985 and intraoperatively after 1986. Hamartoma was the most common of the benign tumors. In benign tumors, the preoperative diagnosis was almost the same as the postoperative one. Of the patients with benign tumors, 78% underwent lobectomy or segmentectomy prior to 1985, and none have undergone any invasive procedures since 1986. Malignant tumors are sometimes difficult to distinguish from benign tumors preoperatively. Therefore, intraoperative histological examinations are necessary in cases in which malignancy is suspected. In such cases, a smaller invasive procedure should be selected due to the possibility of the tumor being benign.

Intraoperative diagnosis of primary ciliary dyskinesia

Primary ciliary dyskinesia refers to clinical disease attributable to congenitally abnormal or absent ciliary motility. Diagnosis typically requires electron microscopy to document aberrant axoneme ultrastructure. Electron microscopy, however, remains inaccurate and inconvenient as a screening test for symptomatic individuals. To avoid delays in diagnosis and to ensure adequacy of the tissue sample, we recommend a tracheal biopsy with an intraoperative histologic examination of ciliary motion. This study included patients evaluated at our institution for recurrent or chronic upper respiratory conditions characterized by chronic sinusitis, chronic mucoid otitis, and chronic bronchitis. A tracheal mucosa biopsy sample was obtained from each patient and was immediately examined in the operating room using light microscopy. If the magnified image demonstrated normal ciliary motility, primary ciliary dyskinesia was excluded and electron microscopy was not ordered. In the absence of normal ciliary motility, the specimen was placed in glutaraldehyde and ultrastructural axoneme morphology was evaluated. In the last 5 years, we have evaluated ciliary motility in 20 patients. Three patients had abnormal ciliary motility identified by light microscopy, and primary ciliary dyskinesia was confirmed histologically in each patient. In the remaining 17 patients, normal ciliary motility was observed, obviating the need for electron microscopy. We advocate intraoperative microscopic study of ciliary motility as a rapid, simple, accurate, and inexpensive technique to screen patients for primary ciliary dyskinesia. (Otolaryngol Head Neck Surg 1997;116:64-7.)

A CASE OF FISTULA CANCER LOCALIZED IN THE FISTULOUS TRACT

An 88-year-old man had multiple anal fistula left untreated for 20 years. Recently, bloody mucous disharge was observed from anal fistula, and was admitted to the hospital for operation of the anal fistula. External openings were located in the direction of 1, 3 and 5 O'clock. Cytologic examination of mucous bloody discharge was performed, but no malignant findings was obtained. An operation for anal fistula was performed, but a possibility of fistula cancer could not be ruled out. Intraoperative histological examination of wall of the anal fistula indicated adenocarcinoma. Abdomono-perineal resection was carried out under the diagnosis of fistula cancer. Histopathologically, it was mucin producting well differentiated adenocarcinoma with papillary structure which was localized within surface of the fistula. It was comparatively early fistula cancer without muscular invasion. This case will suggest fistula cancer may arise from wall of fistula. This type of early stage of fistula cancer has been reported in only 3 cases in our country.

Circumscribed low grade astrocytomas in the dominant opercular and insular region: a pilot study.

Intraoperative mapping techniques allow a reliable identification or exclusion of eloquent brain areas and are well tolerated by the patients. In dominant opercular tumours radical surgery can only be achieved without lasting deficits with intraoperative histological examination of the resection line and mapping. If an early postoperative MRI shows residual opercular tumour in non-eloquent areas re-operation is recommended. In large dominant insular or opercular-insular tumours only biopsy is recommended, because only an incomplete removal can be accomplished, because the trial of radical removal carries a high risk of postoperative deficits due to possible vascular damage of the lenticulo-striate arteries or internal capsule. Because subtotal removal of low grade gliomas does not increase the progression free interval, we would not recommend surgery in these cases, as they carry a significant risk of a further deficit.

C-myc Protein and Ki-67 Antigen Immunodetection in Patients with Uterine Cervix Neoplasia: Correlation of Microcytophotometric Analysis and Histological Data

Cone biopsies were carried out in patients (n = 72) with intraepithelial lesions (CIN 1-3) and squamous microinvasive carcinomas of the uterine cervix. Intraoperative histological examination was achieved in order to obtain small cones with healthy upper resection margins. Also, a tissue fragment was sampled and frozen for the immunocytochemical investigations. Image analysis (SAMBA) of immunoprecipitates was used to evaluate c-myc and Ki-67 antigen expression. Positive c-myc protein staining was observed only on microinvasive carcinomas (70%) and CIN 3 lesions (19%) and was correlated with high Ki-67 immunoreactivity. Ki-67 immunostaining was more extensive (i) in high-grade than low-grade CIN, (ii) in microinvasive carcinomas than in CIN (P ⩽ 0.01), (iii) in large than in small lesions. No correlation could be found between the levels of either c-myc protein or Ki-67 antigen expression and either patient age or cytological features of HPV infection.

The Removal of Porous-Coated Femoral Hip Stems

During a ten-year period, 70 porous-coated femoral hip components of several designs were removed for various reasons. Based on this experience, techniques for the removal of porous-coated stems have evolved and are described, including a newer method for the safe removal of extensively coated bone-ingrown stems. Preoperative roentgenograms were highly predictive of fixation mode as corroborated by intraoperative mechanical testing, gross inspection, and histologic examination. Stable implants (17 bone-ingrown and 11 fibrous tissue-encapsulated) required interface access and division before their removal. Minimal bone damage was incurred, and in no case was reconstruction precluded by stem removal. There were no unplanned cortical perforations. Two minor femoral fractures occurred. The authors present an overall approach and specific surgical techniques that facilitate the safe removal of porous-coated femoral stems on a consistent basis.

Multiple tumors of the biliary tract

Multiple synchronous tumors of the extrahepatic biliary tree are not frequently reported. Over a 2-year period, 54 operative procedures were performed for tumors of the extrahepatic biliary tract or periampullary region. In five of these cases, unsuspected tumors were observed. Of these, one patient had multiple benign papillomatosis of the extrahepatic biliary tree. All four of the other patients were found to have unsuspected small carcinomas of the gallbladder in association with mid- or low bile duct cancer. Multiple tumors of the extrahepatic biliary apparatus may occur more frequently than previously thought, and the incidence of unsuspected gallbladder cancer in association with bile duct cancer may be high. These tumors should be suspected and looked for in each instance by intraoperative endoscopy and careful histologic examination of the gallbladder.

&lt;I&gt;Neurosyphilis Manifesting as a Focal Mass Lesion: Computed Tomographic and Magnetic Resonance Imaging Features&lt;/I&gt;

The computed tomographic (CT) and magnetic resonance (MR) imaging findings in a middle-aged male with cerebral syphilis are described. He presented with convulsive seizures and focal neurological deficits. A CT scan revealed a slightly enhanced, low-density mass in the left parieto-occipital region. MR imaging showed low intensity on T1-weighted images and high intensity on T2-weighted images. He was initially diagnosed as having a low-grade glioma. However, intraoperative histological examination of a small surgical specimen revealed no tumor cells but heavy infiltration of inflammatory cells in the meninges and cerebral parenchyma. Immunostaining for Treponema organisms by the peroxidase-antiperoxidase method was positive. Although the clinical and radiological findings are nonspecific, neurosyphilis should be considered in any patient in whom a nonspecific mass lesion is demonstrated by CT and MR imaging.

CT-assisted stereotactic brain biopsy: value of intraoperative frozen section diagnosis.

In 100 recent CT-guided brain biopsies, the value of intraoperative histologic examination using frozen section technique was evaluated. In 87 of these cases, the biopsy was performed stereotactically. In the remaining 13 cases, a CT-guided free hand technique was used. Of the 100 biopsies performed, adequate tissue for histopathologic diagnosis was obtained in 97, and in three the biopsy was nondiagnostic. In 61 procedures the initial biopsy specimen was adequate for diagnosis. Two specimens were required in 25 and in the remaining cases it was necessary to obtain three to four biopsy specimens before a definitive diagnosis could be made. Ultimately, the histologic diagnosis was made on frozen section examination in 93 of the cases. The lesions identified were neoplastic disease in 83 cases, vascular disease in seven, infectious disease in five, demyelinating disease in one, and radiation necrosis in one. Comparison between the frozen section diagnosis and the final diagnosis based on the permanent sections revealed that they matched in 89 cases (92%). Of the 83 cases of neoplasms the exact grade of malignancy was determined by frozen section to make a final diagnosis revealed that even if the specimen volume was less than 2 mm3, the biopsy was generally successful. The disadvantages of the small sample size obtained through needle biopsy are best overcome by careful targeting and assessment of sample quality by intraoperative frozen section examinations, which will give the definitive diagnosis in most of the cases without paraffin-embedded sections.

Thyroid cancer in children and adolescents

During the period 1972–1982, only 10 of the 105 patients under 20 years of age who underwent thyroid surgery (9.5%) had thyroid cancer. In these 10 cases total thyroidectomy was the treatment of choice. Lymphadenectomy was perfomed in 6 cases following intraoperative histological examination. In all cases, a total body scan was done 30 days after surgical excision. Three patients required complementary radiometabolic therapy. In three cases, lymph node metastases (found during follow-up visits at various times after the first procedure) were removed. All 10 patients are presently alive and without signs of disease. The authors, in their confirmation of the favorable prognosis of thyroid cancer in children and adolescents, stress the advantages of using near-total thyroidectomy and radiometabolic therapy in controlling the disease.