Irregularity Of Outline Research Articles

Morphological effects of chemotherapy on ovarian carcinoma.

Traditionally, advanced stage ovarian carcinoma is treated by debulking surgery followed by chemotherapy. However, in some circumstances preoperative chemotherapy may be given before optimal surgical debulking. This study aims to describe the morphological features found in ovarian carcinoma after chemotherapy because these have not been detailed previously. Histological sections were examined from 18 cases of ovarian carcinoma that had been treated by preoperative chemotherapy. The morphology was compared with any pre-chemotherapy biopsies that had been performed. Tumours were classified as showing morphological features suggesting a good response to chemotherapy (n = 14) or as showing little or no response (n = 4). Serum CA125 values before and after chemotherapy were compared. In all cases, the mitotic activity index (MAI), volume percentage of epithelium (VPE), and mean nuclear area (MNA) of tumour cells were calculated. The preoperative biopsies were all typical ovarian serous or endometrioid adenocarcinomas. Morphological features present in the group responding to chemotherapy included the presence of small groups or single tumour cells in a densely fibrotic stroma. Tumour cells were characterised by both nuclear and cytoplasmic alteration, making accurate tumour typing and grading impossible. Nuclear features included the presence of bizarre enlargement with hyperchromatism, irregularity of outline, and chromatin clumping or smudging. Cytoplasmic alterations included intense eosinophilia, vacuolation, or foam cell change. There were pronounced stromal changes of fibrosis, inflammation, collections of foamy histiocytes, cholesterol cleft formation, haemosiderin deposition, fat necrosis, and dystrophic calcification, including the presence of many free psammoma bodies. There was no correlation between morphological response and biochemical response, as determined by serum CA125 values. In all nine cases in which pre-chemotherapy and post-chemotherapy biopsies were available, the MNA increased post-chemotherapy (p = 0.007, paired Wilcoxon test) and in six of nine cases the MAI decreased (p = 0.093). Because preoperative chemotherapy is being used increasingly in the management of ovarian cancer, pathologists should be aware of the resultant morphological effects. Accurate tumour typing and grading is impossible. In some cases, it may be difficult to confirm the presence of residual tumour, making it imperative that pre-chemotherapy tissue biopsies are obtained. Definite confirmation of residual tumour may require the examination of multiple histological sections from areas showing pronounced stromal changes, sometimes with multiple levels and immunohistochemistry. In the absence of definite residual tumour, the report should state that the features are consistent with the prior presence of tumour.

Improved ultrasound detection of renal scarring in children following urinary tract infection

A system for defining renal scarring on ultrasound is proposed and compared with DMSA scintigraphy. Renal scarring was assessed with ultrasound in children following urinary tract infection (UTI) using the following criteria: (1) proximity of sinus echoes to cortical surface; (2) loss of pyramids; (3) irregularity of outline; (4) loss of definition of capsular echo; and (5) calyceal dilatation. Three hundred and thirty-nine consecutive ultrasound scans (US) and DMSA scintigrams, comprising 648 kidneys, were performed and reported blindly and the results were compared. Using DMSA scintigraphy as the gold standard, ultrasound had a positive predictive value of 93% and a negative predictive value of 95%. Ultrasound disagreed with DMSA scintigraphy in 5.2% of kidneys. On review of the cases of disagreement where arbitration was possible by comparison with other imaging, ultrasound was incorrect in 10 kidneys and DMSA was incorrect in 13. We conclude that the sensitivity in the ultrasound detection of renal scarring can be greatly improved using this method. If no scars were detected at ultrasound an alternative explanation for an abnormal DMSA scintigram should be sought.

Ultrasonic detection of non-palpable seminal vesicle invasion: a clinicopathological study.

In an effort to identify reliable criteria for detecting seminal vesicle invasion (SVI) with transrectal ultrasonography (TRUS) in patients with clinically localised prostate cancer, we reviewed the pre-operative sonograms in 230 patients who underwent radical retropubic prostatectomy; 49 patients (21%) had pathologically confirmed SVI. Conventional sonographic criteria for SVI (asymmetry, distension, atrophy, abnormal echogenicity and irregularity in outline) were present in 58 patients, but only 16 (28%) had pathologically confirmed SVI. On the basis of the results of a preliminary comparison of radical prostatectomy specimens and TRUS, we had revised our criteria for the recognition of SVI: (1) a hypoechoic lesion at the base of the prostate (within 10 mm of the seminal vesicle); (2) an "adhesion sign" resulting from the loss of the echo reflections from the normal fat plane between the prostate and the seminal vesicle; (3) "posterior convexity" of the seminal vesicles. When we reviewed the 230 sonograms retrospectively, we found a hypoechoic tumour at the base in 70 patients, of whom 37 had SVI (positive predictive value (PPV) 53%). An adhesion sign was found in 16 patients, 12 of whom had SVI (PPV 75%). Posterior convexity was present in 4 patients, all of whom had SVI. If any one of our sonographic signs was present, the overall accuracy (83%), sensitivity (90%) and positive predictive value (51%) were significantly better than with any one of the conventional criteria. Patients with SVI were also more likely to have a high serum prostate specific antigen (PSA) level. The PPV for SVI of a PSA level > or = 10 ng/ml was 38%. If the PSA was > 10 ng/ml and TRUS was positive (> or = 1 of our sonographic criteria), 16 (62%) of 26 patients had SVI. If the PSA was < 10 ng/ml and TRUS was negative, only 3 (3%) of 86 patients had SVI. It was concluded that the conventional criteria for detecting SVI on ultrasonography are not accurate in patients with early stage prostate cancer. There are, however, reliable criteria that predict SVI with reasonable accuracy and these criteria, combined with the serum PSA levels, can stratify patients into those with a low risk and those with a high risk of SVI.

Arthrographic findings in the temporomandibular joint in patients with rheumatic disease

Hypocycloidal multisection tomography and lower-space arthrotomography with videofluoroscopy were performed on 20 symptomatic temporomandibular joints (TMJs) of 17 patients. All patients (16 women, one man, aged 17 to 38 years) had definite or suspected rheumatoid arthritis (adult or juvenile type), ankylosing spondylitis, or psoriatic arthropathy. Bone abnormalities were found in 14 TMJs, primarily cortical erosion (11 joints), but also condylar flattening (three joints). Irregularity in outline of the contrast material, bone contour-contrast material gaps, evidence of adherent discs and/or small joint compartments indicated synovial hyperplasia/pannus formation in 15 joints. Six of these (four with normal disc position) showed perforation between the joint compartments. In those with normal disc position the perforation seemed to occur in the central portion. Ten of the 15 joints had normal disc position; the remaining five had anterior disc displacement without reduction. One joint showed only disc displacement. Most joints with bone abnormalities (12 of 14) showed arthrographic signs of rheumatic involvement. Such signs were also observed in two of the six joints with no bone abnormalities, indicating the value of arthrography in the early diagnosis of patients with rheumatic disease and TMJ problems.

Temporomandibular joint arthrography following surgical treatment of internal derangements.

Arthrograms of the temporomandibular joint were obtained in 20 symptomatic joints that had previous reconstructive arthroplasty with disk repositioning because of internal derangements. Preoperative arthrograms were available for comparison in 18 joints. Symptoms resulting in a postoperative arthrogram included pain, limited ability to open the mouth, and clicking of the joints. Postoperative arthrographic findings included limited anterior translation of the condyle (90%), irregularity in outline of the intraarticular contrast agent (60%), a conical configuration of the posterior recess (25%), decreased size of the joint (28%), anterior displacement of the meniscus (25%), and perforated meniscus (15%). Many of these findings may have resulted from fibrosis and scarring, which may be a response to intraarticular bleeding. The mechanism by which the fibrosis causes the postsurgical arthrographic features is discussed.

Session I: Papillary carcinoma

Abstract In addition to a description of the basic criteria for the diagnosis of papillary carcinoma, a review of discussions by all workshop participants on the illustrative cases is presented. Areas of consensus Included the following: (1) classification of mixed papillary and follicular carcinomas as papillary, regardless of follicular dominance; (2) recognition of three morphological variants-follicular, encapsulated, and diffuse sclerosing; (3) nonspecificity of individual histological criteria, with the necessity to utilize a combination of characteristic features as guidelines for establishing a diagnosis; (4) citing of nuclear features as probably the most important diagnostic criteria, le, increased N/C ratio, irregularity in outline, and paleness of staining (ground glass appearance); (5) grading of tumors on the basis of either cytological or architectural characteristics remains of unproven prognostic value. (Gross extent of tumor at the first operation remains the most valuable single prognostic criterion.); (6) defining small carcinomas by size rather than using the imprecise term occult with its variable definitions including some clinically evident tumors; (7) classifying as undifferentiated those carcinomas presenting a mixed papillary and anaplastic appearance at the time of the first operation, and retaining the papillary designation for papillary cancers which later undergo dedifferentiation; and (8) recognition that thyroglobulin is a constant and keratin an inconstant tumor cell marker, with the latter not specific for distinguishing papillary carcinomas or from hyperplastic adenomas.

Determination and characterization of hexokinase in thyroid cancer and benign neoplasms.

Hexokinase (ADP: D-hexose-6-phosphotransferase, EC 2.7.1.1) was studied in human thyroid carcinomas (n = 11), follicular adenomas (n = 32), and normal thyroid tissue (n = 21). The specific activity was significantly increased in carcinoma (0.163 +/- 0.083 U/mg protein) compared with normal tissue (0.030 +/- 0.010 U/mg protein) (P less than 0.001). Specific activities of follicular adenomas are rather heterogeneous, but when subdivided into three groups according to histopathologic criteria, a significant difference was found between follicular adenomas group I and II and follicular adenomas group III. A lesser cellular differentiation of adenomas is indicated by the lower degree or even absence of colloid production and follicle formation. A higher proliferation rate may be assumed on the grounds of the irregularities in outline, the often defective pseudocapsule, and signs of compression of the surrounding tissue. The highest specific activity in adenomas was found in the group with the highest proliferative activity, i.e., group III, whereas the lowest specific activities were found in adenomas with the lowest grade of proliferation, i.e., group I; the former was comparable with values found in carcinomas and the latter was comparable with values found in normal thyroid tissue. An interesting difference was found when the compartmentation of hexokinase was compared in carcinomas of different degree of differentiation. In papillary carcinomas a significantly lower proportion of hexokinase (HK) is present in the cytosol in comparison to follicular and undifferentiated carcinomas. In carcinomas more HK II and less HK I was found in comparison with normal thyroid tissue. In contrast hexokinase isozyme composition and compartmentation in adenomas were not different from normal thyroid tissue.

Computed tomography in pancreatic disease.

Computed tomography (CT) of the pancreas has been evaluated in 50 patients with established exocrine pancreatic disease and 20 patients without pancreatic disease. Increase in size, irregularity in outline and heterogeneity of composition of the pancreas implied disease but were in no way specific to any particular disease entity. In acute pancreatitis, following complete resolution, the pancreas appeared normal whereas incomplete resolution was associated with non-specific swelling and heterogeneity of density. The extent and location of pseudocysts could be accurately delineated. In chronic pancreatitis, duct calculi, duct dilatation and large intrapancreatic cysts aided the differentiation between focal enlargement due to chronic pancreatitis and expansion due to cancer. Hepatic metastases and abnormalities of the biliary system seen in association with cancer further aided this differentiation.

Effect of saramycetin on the fine structure of Histoplasma capsulatum.

WhenHistoplasma capsulatum yeast cells were grown in the presence of partially inhibitory concentrations of saramycetin, electron microscopy revealed that the proportion of apparently damaged cells was a function of the concentration of the antibiotic. Evidence of early damage consisted of irregularity of outline, followed by progressive lysis of internal structures leading to residual dense granules, membranes, and the cell wall. Normal yeast cells of the strain studied were found to possess intranuclear bodies of a type apparently not previously described.

The distribution of stresses in the vicinity of mine workings with consideration of irregularities in outline

The distribution of stresses in the vicinity of mine workings with consideration of irregularities in outline

Some radiological aspects of primary intrathoracic neurogenic tumours: Based on a review of 19 cases

Summary 1. A critical survey of 19 proven cases of primary intrathoracic neurogenic tumours was made to try to correlate the radiological, surgical, and pathological findings. 2. The importance of lobulation or irregularity of outline, however slight, as being indicative of degeneration or malignant transformation is emphasized. 3. It is suggested that radiological differentiation between neurofibromata (sheath tumours) and ganglioneuromata (cell tumours) is possible. 4. The differential diagnosis is discussed.

Roentgenographic Diagnosis of Neoplasms of the Peri-Ampullary Region and Head of the Pancreas

Radical excision of carcinoma of the ampulla of Vater and of the head of the pancreas, together with the entire duodenum, is feasible (Diagram 1). For this reason there should be increased interest in the radiographic diagnosis of neoplasms in these regions. Peri-ampullar lesions should be more readily detected than carcinomas in the head of the pancreas, since the latter, especially in the operable stage, may not produce changes in the duodenal wall or contour of the duodenal curvature. The term “ampullar carcinoma” is commonly employed to designate neoplasms of the true ampulla as well as those arising from the papilla of Vater or immediate vicinity. Ampullar carcinomas may be polypoid and protrude into the duodenal lumen. When large, they are readily observed. Such an example is shown in Figure 1. This carcinoma was resected transduodenally, with reimplantation of bile and pancreatic ducts and the patient remains well five years later, a roentgenogram now affording practically a normal picture of the duodenum. A neoplasm arising within the ampulla expands the latter, affording the appearance of a smooth enlarged papilla of Vater. Theoretically this should be easily demonstrable but inability to produce marked distention of the duodenum by barium probably accounts for frequent failure of detection at fluoroscopy. The surgical specimen shown in Figure 2, consisting of the entire duodenum and the head of the pancreas, resected for ampullar carcinoma extending up the common duct, shows an enlarged and prominent papilla which was not discovered on fluoroscopy. A roentgenogram made three months after operation, as depicted in Diagram 1, shows the disposition of barium in the altered upper alimentary tract (Fig. 2B). Ampullar carcinomas may also afford flattened ulcerations with raised rolled edges (Fig. 3A). These may produce consistent irregularities in outline of the duodenal wall accentuated by a stiffness of the involved segment (Fig. 3B). Extensive infiltration of the duodenal wall by ampullar carcinoma, or carcinoma primary in the second portion of the duodenum, causes great distortion of the wall and rigidity of the involved segment, and should be easily detected. In these cases, also, normal mucosal markings are replaced by irregular coarse markings and there may be polypoid masses protruding into the lumen.

Roentgen Diagnosis of Fungous Infections of the Gastro-Intestinal Tract

The gastro-intestinal tract is the site of fungous infections much less frequently than are the lungs or skeletal system. Of the relatively small number of cases in the literature, the great majority are actinomycosis. Blain and Sanford and Voelker estimated that 18 per cent of the cases of actinomycosis reported in the United States up to 1932 were intraabdominal, involving the appendix, intestine, or liver. Despite the rather frequent occurrence of buccopharyngeal lesions, reports of actinomycosis of the stomach, duodenum, and jejunum are rare in the literature. It has been suggested that the acid secretions of the stomach may kill the fungus or inhibit its activity, while the fluid contents of the small intestine are not likely to produce abrasions of the mucosa through which the streptothrix might invade the deeper tissues. An attack of appendicitis, however, may give the opportunity for which the organism is waiting, with the result that actinomycosis of the cecum and appendix is relatively common. In 1928 Sir W. I. de Courcy Wheeler reported a rare case of actinomycosis of the duodenum and jejunum. The patient was a forty-year-old male who had been ill four months with vague abdominal pains and loss of appetite and weight. His temperature had ranged from 99° to 101° during his illness and he had experienced one attack of hematemesis shortly after hospitalization. No hydrochloric acid was found in the gastric contents. The x-ray examination was incomplete (due to inadequate equipment), but the stomach was found to be dilated and hypotonic. There were diffuse narrowing of the pyloric segment and gross irregularities of outline in both curvatures. A large six-hour residue was demonstrated, and the impression gained by the x-ray study was that of pyloric obstruction due to carcinoma. At operation the stomach and first portion of the duodenum were considered normal. A tumor the size of a bantam's egg was found in a loop of jejunum 12 inches from the duodenojejunal juncture. The mass was adherent to the omentum and when the adhesions were freed the isolated tumor appeared red and acutely inflamed on the surface, very similar in appearance to an acutely inflamed appendix before rupture. The loop of jejunum containing the mass was resected but the patient died on the eighth postoperative day. Postmortem examination showed leakage at the site of the anastomosis and a second area of ulceration was found in the third portion of the duodenum similar to the one resected from the jejunum. Blain reported a case of actinomycosis of the stomach in a thirty-seven-year old male, in 1933. The patient complained of epigastric pain one hour after meals, the pain being relieved by food or baking soda. Roentgen examination revealed a deformity of the stomach which affected the passage of the meal through the pylorus but did not produce obstruction. A diagnosis of chronic gastric ulcer was made.

NEUROFIBROMATOSIS WITH OCULAR CHANGES AND INVOLVEMENT OF THE THORACIC SPINE

Pigmentation of the skin and multiple neurofibromas are characteristic of Recklinghausen's disease, but numerous other manifestations are seen. 1 Changes in the bone have been observed in cases of neurofibromatosis. Brooks and Lehman, 2 Castronuovo, 3 Camp, 4 Camp, Adson and Shugrue, 5 Gould, 6 Weiss, 7 Adrian, 8 and Stalmann 9 reported cases with various associated changes in the bone, including scoliosis, abnormality of growth, irregularity of outline, central and subperiosteal cysts, pedunculated subperiosteal tumors and pseudo-arthrosis. Siegmund 10 reported a case of neurofibromatosis with bony cavities of the lumbar and sacral vertebrae lined by herniations of the dura and accompanied by aneurysmal dilatations of vertebral arteries. Ocular changes associated with Recklinghausen's disease are also recorded. Goldstein and Wexler 11 described a case of melanotic tumors of the iris with orbital neurofibromas and called attention to the frequent occurrence of orbital neurofibromatosis accompanied by pigmented nevi of the lids,

EPIPHYSITIS OF THE OS CALCIS.

In children, particularly in boys, between the ages of seven and one-half and seventeen years, the occurrence of painful heels should suggest the possibility of epiphysitis of the os calcis. The roentgenographic findings are characteristic,—fragmentation , rarefaction, narrowing, and irregularity in outline of the epiphysis, with later excessive calcification. The condition is self-limiting, and recovery occurs spontaneously when the epiphyses unite at about the age of seventeen years The etiology has not been definitely established, but the role of trauma seems to be of some significance.

EARLY TREPHINING IN DISEASES OF BONES.

[Read to the Section on Surgery and Anatomy, June, 1883.] A careful study of the vascular relations of a bone to its periosteum and medulla, leads to the conviction that there can be no serious deviation from the normal in either without implication of the remaining parts. Of the three component parts of a bone, the osseous tissue proper, owing to its comparatively passive nutritive state, is naturally least liable to inflamatory changes. As a rule, its morbid conditions are therefore secondary in character, and follow upon disturbances of the periosteum or medulla. From the superficial position of the former, its lesions, whether primary or secondary, are always easily recognized. Those of the medulla, on the other hand, are as usually ignored until the periosteum and the bone itself have become involved in a manner to attract attention by irregularities of outline, swelling of the soft parts, abscesses and fistulae.