Mm In Greatest Dimension Research Articles

Traumatic neuromas of the penis: a clinical, histopathological and immunohistochemical study of 17 cases

We present 17 penile traumatic neuromas. The mean patient age at presentation was 38 years (range 23-59 years). The most common site involved was the penile shaft. The lesions ranged from 1 to 7 mm in greatest dimension. The clinical diagnosis in all cases included condyloma acuminatum. In all cases, a history of trauma because of prior biopsy and/or circumcision was found. Histologically, all lesions showed similar features consisting of an increased number of dermal nerve bundles embedded within a fibrous stroma. Often, single or multiple Meissner corpuscle-like structures were noted in the papillary dermis. Our study suggests that circumcision or other forms of trauma to the skin of the penis likely plays an important role in the pathogenesis and clinical presentation of this peculiar neural neoplasm. We call attention to this entity because it is often clinically misdiagnosed as condyloma acuminatum.

Noninvasive diagnosis of solitary pulmonary lesions in cancer patients based on 2‐fluoro‐2‐deoxy‐D‐glucose avidity on positron emission tomography/computed tomography

2-Fluoro-2-deoxy-D-glucose (FDG) imaging is highly accurate for assessing solitary pulmonary nodules (SPNs) in patients without known malignancy. In the current study, the authors evaluated FDG-positron emission tomography/computed tomography (PET/CT) for the characterization of SPN in cancer patients. FDG-PET/CT was performed in 56 cancer patients to evaluate SPNs that measured 15 +/- 8 mm in greatest dimension. The diagnosis was confirmed by histology (n = 34 patients), or by CT or clinical follow-up (n = 22 patients). The performance of PET/CT was calculated for visual and semiquantitative assessment and was related to SPN size, location, histology, and time after initial cancer diagnosis. Malignancy was diagnosed in 27 of 56 SPNs (48%; 18 second primary tumors and 9 metastases). There were 26 true-positive PET/CT studies (17 second primaries and 9 metastases), 5 false-positive studies, 24 true-negative studies, and 1 false-negative study. The sensitivity of PET/CT for diagnosing malignant SPN in patients with cancer was significantly greater for visual analysis than for semiquantitative analysis (96% vs 89%, respectively; P < .05). Specificity and accuracy were similar for both methods (83% and 89% vs 93% and 91%, respectively). The presence of low-intensity FDG uptake increased the detection rate of malignancy from 4% in non-FDG-avid SPNs to 40%, mainly in second primary tumors. False-positive results were more frequent with lower than mediastinal uptake versus higher than mediastinal uptake (3 of 5 SPNs vs 2 of 26 SPNs, respectively; P < .01) and in SPNs >10 mm. FDG imaging was highly accurate for the diagnosis of malignant SPNs in patients with cancer, similar to the general population. The presence of any FDG avidity had significantly greater sensitivity than semiquantitative analysis. The current results indicated that lower than mediastinal uptake should be explored cautiously, particularly for second primary tumors, whereas no FDG avidity was a better predictor of SPN benignity than very low uptake.

Intratarsal Epidermal Inclusion Cyst

To report 3 cases of epidermal inclusion cyst that arose within the tarsus, an unusual site of origin. A retrospective review of medical records of patients undergoing excision of eyelid epidermal inclusion cysts by one surgeon (MJL) over a decade revealed 3 cases of intratarsal epidermal inclusion cyst. Initially, these lesions resembled chalazia and were first addressed with incision and curettage. There was recurrence of the cyst in all the 3 cases from 1 to 4 months, and subsequent complete excision was necessary. At surgery in each of these cases a cyst arising within the tarsus was encountered. Eventually, the tarsus containing the base of the cyst was excised to ensure complete removal. The cysts were approximately 8 mm to 10 mm in greatest dimension and had yellowish-white gelatinous contents. Histopathologic evaluation revealed keratin-filled cysts arising from tarsus and lined by stratified keratinized epithelium. In one of the cases the tarsal tissue around the cyst wall showed epidermal elements presumably derived from sebaceous gland. There have been no recurrences after complete excision (follow-up range, 9-60 months). Intratarsal epidermal inclusion cysts share some clinical features with chalazia. Lack of inflammation, lack of fluctuation in size, gradual continued slow growth, and delayed onset of recurrence may help to differentiate tarsal cyst from recurrent chalazion. Incision and curettage, however, is not effective long-term treatment for this entity. Total excision of the cyst including full-thickness excision of tarsus at the cyst's base of origin is suggested for definitive treatment.

Endometrial-Peritoneal Interactions during Endometriotic Lesion Establishment

The pathophysiology of endometriosis remains unclear but involves a complex interaction between ectopic endometrium and host peritoneal tissues. We hypothesized that disruption of this interaction would suppress endometriotic lesion formation. We hoped to delineate the molecular and cellular dialogue between ectopic human endometrium and peritoneal tissues in nude mice as a first step toward testing this hypothesis. Human endometrium was xenografted into nude mice, and the resulting lesions were analyzed using microarrays. A novel technique was developed that unambiguously determined whether RNA transcripts identified via microarray analyses originated from human cells (endometrium) or mouse cells (mesothelium). Four key pathways (ubiquitin/proteasome, inflammation, tissue remodeling/repair, and ras-mediated oncogenesis) were revealed, demonstrating communication between host mesothelial cells and ectopic endometrium. Morphometric analysis of nude mouse lesions confirmed that necrosis, inflammation, healing and repair, and cell proliferation occurred during xenograft development. These processes were entirely consistent with the molecular networks revealed by the microarray data. The transcripts detected in the xenografts overlapped with differentially expressed transcripts in a comparison between paired eutopic and ectopic endometria from human endometriotic patients. For the first time, components of the interaction between ectopic endometrium and peritoneal stromal tissues are revealed. Targeted disruption of this dialogue is likely to inhibit endometriotic tissue formation and may prove to be an effective therapeutic strategy for endometriosis.

Protocol for the Examination of Specimens From Patients With Primary Carcinomas of the Colon and Rectum

The College of American Pathologists offers these protocols to assist pathologists in providing clinically useful and relevant information when reporting results of surgical specimen examinations. The College regards the reporting elements in the “Surgical Pathology Cancer Case Summary (Checklist)” portion of the protocols as essential elements of the pathology report. However, the manner in which these elements are reported is at the discretion of each specific pathologist, taking into account clinician preferences, institutional policies, and individual practice. The College developed these protocols as an educational tool to assist pathologists in the useful reporting of relevant information. It did not issue the protocols for use in litigation, reimbursement, or other contexts. Nevertheless, the College recognizes that the protocols might be used by hospitals, attorneys, payers, and others. Indeed, effective January 1, 2004, the Commission on Cancer of the American College of Surgeons mandated the use of the checklist elements of the protocols as part of its Cancer Program Standards for Approved Cancer Programs. Therefore, it becomes even more important for pathologists to familiarize themselves with these documents. At the same time, the College cautions that use of the protocols other than for their intended educational purpose may involve additional considerations that are beyond the scope of this document.

Detection of lymph node micrometastases in patients with squamous carcinoma of the head and neck

While the significance of large cervical node metastases in patients with head and neck squamous carcinomas is well established, the import of a finding of regional nodal micrometastases (where a micrometastasis is defined as a metastatic deposit greater than 0.2 mm and not greater than 2.0 mm in greatest dimension) or isolated tumor cells in those patients is less clearly understood. Some earlier investigators have suggested that finding micrometastases does not have an impact on prognosis; some later investigators, however, have taken issue with this position, arguing that finding either micrometastases or isolated tumor cells might portend a poorer prognosis for head and neck cancer patients. At this juncture, it is difficult to advance a single recommendation for handling a finding of micrometastases or isolated tumor cells. It would be helpful if two courses of action were followed: first, while the detection of micrometastases and isolated tumor cells remains an investigatory practice, data should be collected and analyzed with an eye to discerning whether such findings are indeed of significance to the individual head and neck cancer patient. Second, rigorous definitions of micrometastases and isolated tumor cells (such as the definitions suggested here) should be developed and widely employed so as to permit ready comparison between the results as they are reported by different investigators.

Completely endoscopic resection of glioblastomas using a transparent conduit: Proof of concept

2066 Background: Completely endoscopic resection of high grade gliomas has not been reported in a neurosurgical case series. Methods: Using frameless image guidance, an 11.5 mm cylindrical transparent port (endoport) is established as a transcortical conduit into the lesion. The port is introduced through a small cortisectomy. Microsurgical instruments, suction, and bipolar cautery are all introduced through the port as needed to facilitate resection. Five patients (four female, one male) underwent tumor resection using the fully endoscopic method. Age varied from 37–74 years (mean 57.8 years). All patients presented with some degree of confusion (two with somnolence), two patients (40%) had significant headache, and 3 patients (60%) were hemiparetic at the time of evaluation. Three tumors were in the left frontal region, one tumor was a butterfly glioma, and one tumor was in the right centrum semiovale. Tumor size varied from 41 to 65 mm in greatest dimension (mean 51.4 mm). Results: All patients demonstrated pathologically confirmed glioblastomas. On post-operative MRI, one patient had a gross total resection, two patients had >95% radiographic resection, and two patients had subtotal resection. No patient demonstrated any radiographic evidence of injury to surrounding brain as a result of resection. No patient suffered a post-operative complication or a new neurological deficit. One patient was taken back to the operating room for tumor progression well after discharge. Conclusions: Fully endoscopic resection of high-grade gliomas through a minimal access port is feasible and may be a safe alternative to open surgical extirpation. The degree of underlying white matter injury and the size of the cortisectomy for tumor resection may be less than with conventional methods of tumor removal. Further studies are warranted to determine whether or not this technique is safer than a standard tumor resection in the setting of glioblastoma. No significant financial relationships to disclose.

W1393 Is Tumor M2-Pyruvate Kinase (PK) a Potential Marker for the Discrimination Between Chronic Pancreatitis and Pancreatic Cancer?

were determined. MIA PaCa-2 pancreatic cancer cell lines with functional mitochondria (rho+) and the same lines without functional mitochondria (rhoo) (J. Biol. Chem. 281:37416, 2006), were treated with ascorbate and clonogenic survival determined. The oxygen electrode method was used to determine H2O2 production. MIA PaCa-2 tumor cells (2 x 106) were delivered subcutaneously into the flank region of nude mice and allowed to grow until they reached 3 mm in greatest dimension at which time they were randomized to receive either ascorbate (4g/kg) or osmotically equivalent i.p. saline as a control (1 M) given to mice i.p. every day for two weeks. Results: There was a time and dose-dependent increase in measured H2O2 productionwith increased concentrations of ascorbate. Ascorbate decreased clonogenic survival and viability in pancreatic cancer cell lines in a dose-dependent manner. Ascorbate had no effect on the H6c7 cell line, but decreased viability in the H6c7 cell lines that express K-ras oncogene. Ascorbate (5 and 10 mM) decreased viability in all human pancreatic cancer cell lines tested. In rho+ cells, ascorbate resulted in a dose-dependent decrease in clonogenic survival, but no cytotoxicity in the rhoo cells. The group of animals that received ascorbate had significantly slower tumor growth when compared to the controls receiving osmotically equivalent saline (P < 0.0001, n = 5-8/group). On day 15 of treatment, there was a 3.5fold decrease in tumor growth in animals receiving ascorbate when compared to controls. Conclusions: Pharmacological doses of ascorbate, achievable in humans when given intravenously, may have potential for therapy in pancreatic cancer. The ascorbate-induced cytotoxicity in pancreatic cancer cells may be mediated by a mitochondrial mechanism.

Subependymoma revisited: clinicopathological evaluation of 83 cases

Subependymomas are rare ependymal neoplasms. To date, a large clinicopathologic study of these benign neoplasms treated with modern neurosurgical techniques has not been reported. Eighty-three cases of subependymoma were retrieved from the files of the Armed Forces Institute of Pathology. Clinicopathological features were reviewed; chromogenic in situ hybridization analysis for chromosome 22 was performed (n = 8), and patient follow-up was obtained (n = 34). Overall, the patients included 68 males and 15 females, 1.5 to 85 years of age (mean, 51.0 years). Twenty-seven cases were discovered at autopsy and the remaining were surgical specimens (n = 56). Tumors arose in the posterior fossa (n = 43), lateral ventricles (n = 37), spinal cord (2) and only one arose in the temporal horn. Tumors ranged in size from 2.0 mm to 60 mm in greatest dimension (mean, 23.0 mm). Eighteen-percent (15/83) of subependymomas exhibited a mixed histologic pattern; that is, subependymoma together with another glial tumor. The most common mixture (13/15) was subependymoma and ependymoma. Surgical excision was used in all symptomatic patients; 10 patients received radiation. Four patients developed a recurrence due to incomplete excision. All patients were without evidence of disease at the last follow-up: alive (n = 28) or dead (n = 8). Age is the only variable found to be significantly associated with survival. Currently, surgical methods result in an excellent long-term clinical outcome. Subependymomas do not appear to be associated with NF2 mutations.

Renal Tract Calculi: Comparison of Stone Size on Plain Radiography and Noncontrast Spiral CT Scan

Noncontrast spiral CT (NCCT) has emerged as the investigation of choice in patients presenting with renal-tract calculi. As management guidelines are based on stone size measured on plain radiography of the kidneys, ureters, and bladder (KUB), it is important to assess the accuracy of stone size measured on NCCT compared with KUB films. The NCCT and KUB studies obtained from 24 patients (27 stones) presenting to the emergency department at a major metropolitan hospital were analyzed randomly and independently by two urologists and one uroradiologist. The NCCT scans were assessed separately from the KUB films. Only size in greatest dimension and stone location were recorded. The stone size was 2 to 38 mm on NCCT scans and 2 to 46 mm on KUB films. The mean stone size was 6.773 +/- 6.146 mm and 7.747 +/- 7.866 mm, respectively (P = 0.0398; Student's t-test). Almost three fourths (70%) of the stones were larger on KUB films than they were on NCCT scans, with a mean difference -0.974 mm (95% confidence interval -5.652, 3.703) for NCCT. Spiral CT underestimates stone size by approximately 12% compared with KUB films. This error may impact stone management as outlined in guidelines published by the American Urological Association, particularly for stones about 5 mm in greatest dimension. These patients may initially be managed conservatively when intervention would be more appropriate.

Detection of occult sentinel lymph node micrometastases by immunohistochemistry in breast cancer

Occult metastases, by definition, are not detected on initial examination. They may be present on slides but missed during screening or may be present in paraffin embedded tissue blocks and undetected without additional levels. Anticytokeratin immunohistochemistry (CK IHC) enhances detection of occult metastases, particularly micrometastases (> 0.2 mm but not larger than 2.0 mm) or isolated tumor cell clusters (< or = 0.2 mm). This study defines the rate at which pathologists miss metastases on CK IHC of sentinel lymph nodes (SLN). CK IHC sections 0.5 and 1.0 mm from the original surface of SLN tissue blocks were screened by pathologists using standard bright field light microscopes (LM) and by supervised computer assisted cell detection (CACD). All blocks were from breast cancer patients, initially classified 'node negative' on review of routinely stained sections from the surface of each block. Cases missed by LM screening but detected by CACD defined false negative screens. Of 236 cases screened, LM detected 34 (14.4%; 95% CI: 9.6-20.2) cases and, in the 202 cases negative by LM, CACD detected an additional 30 (14.9%; 95% CI: 9.6-21.2%) cases with occult metastases. Occult metastases missed by LM screening ranged from 0.01 to 0.1 mm in greatest dimension. The probability of missing an occult metastasis < or = 0.02 mm; < or = 0.05 mm, and < or = 0.10 mm was 75%, 69.2%, and 61.2%, respectively. No occult metastases larger than 0.10 mm were missed by LM screening. Pathologists screening the CK IHC stained slides may frequently miss detecting metastases < 0.10 mm.

The Presence of a CD21+ Follicular Dendritic Cell Network Distinguishes Invasive Quilty Lesions From Cardiac Acute Cellular Rejection

Quilty lesions are a significant source of interobserver variability and overdiagnosis of rejection. These lesions, characterized by a central aggregate of B-cells with a rim of T-cells admixed with capillary-sized blood vessels, exhibit an organization similar to lymphoid tissue. We postulated that this organization is dependent on a follicular dendritic cell (FDC) network and that the presence of such a network would be useful in distinguishing invasive Quilty lesions from acute cellular rejection. Thirty-nine lesions of acute cellular rejection [International Society for Heart and Lung Transplantation (ISHLT) grade 1A/1B, n = 7; grade 2, n = 13; grade 3A/3B, n = 18; grade 4, n = 1] and 32 invasive Quilty lesions were collected from our pathology archives. Immunohistochemical staining for CD21 was used to determine the presence of a FDC network. A compact CD21 FDC network was present in 24 of 32 invasive Quilty lesions, and, more significantly, in 23 of 24 invasive Quilty lesions measuring larger than 0.3 mm in greatest dimension. When present, the FDCs were in the center of the lesion and the number of positive cells was proportional to the size of the lesion. A FDC network was completely absent in all but one of the 39 lesions of acute cellular rejection. Review of the H&E material from this single case showed features more consistent with a diagnosis of an invasive Quilty lesion. The presence of a CD21 FDC network is a reliable diagnostic tool to differentiate invasive Quilty lesions from acute cellular rejection, especially in those lesions (> 0.3 mm) that are most likely to be overdiagnosed as moderate or severe acute cellular rejection (sensitivity 96%, specificity 100%, positive predictive value 100%).

Updated Protocol for the Examination of Specimens From Patients With Carcinomas of the Prostate Gland

T protocol is intended to assist pathologists in providing clinically useful and relevant information as a result of the examination of surgical specimens. Use of this protocol is intended to be entirely voluntary. If equally valid protocols or similar documents are applicable, the pathologist is, of course, free to follow those authorities. Indeed, the ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of the individual circumstances presented by a specific patient or specimen. It should be understood that adherence to this protocol will not guarantee a successful result. Nevertheless, pathologists are urged to familiarize themselves with the document. Should a physician choose to deviate from the protocol based on the circumstances of a particular patient or specimen, the physician is advised to make a contemporaneous written notation of the reason for the procedure followed. The College recognizes that this document may be used by hospitals, attorneys, managed care organizations, insurance carriers, and other payers. However, the document was developed solely as a tool to assist pathologists in the diagnostic process by providing information that reflects the state of relevant medical knowledge at the time the protocol was first published. It was not developed for credentialing, litigation, or reimbursement purposes. The College cautions that any uses of the protocol for these purposes involve considerations that are beyond the scope of this document.

Clinical outcomes of single‐fraction stereotactic radiation therapy of lung tumors

The objective of the current study was to investigate the effects and the morbidities of single-fraction stereotactic radiation therapy (SRT) for lung tumors. A Microtron device was modified to deliver stereotactic irradiation under respiratory gating. Between August 1998 and December 2004, 59 malignant lung tumors (11 primary tumors, 48 metastases) that measured < 40 mm in greatest dimension were treated by single-fraction SRT. Nine tumors received a minimal dose of < 30 grays (Gy), and 50 tumors received a minimal dose of > or = 30 Gy. The macroscopic target volume ranged from 1 cc to 19 cc (mean, 5 cc). The 1-year and 2-year local progression-free rates (LPFRs) were 93% and 78%, respectively. The overall survival rate was 76.5% at 1 year and 41% at 2 years. Local regrowth of the irradiated tumor was a direct cause of death in two patients. Only the minimal radiation dose to the reference target volume tended to have an influence on the LPFR (P = 0.068). The 2-year LPFRs for patients who received irradiation doses of > or = 30 Gy and < 30 Gy were 83% and 52%, respectively. With regard to morbidities, Grade 3 respiratory symptoms (according to the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer late radiation morbidity scoring scheme) were noted in one patient. The results from the current study suggested that single-fraction SRT was tolerable and was capable of attaining excellent local control in patients who had malignant lung tumors that measured < 4 cm in greatest dimension.

Hearing Preservation and Facial Nerve Outcomes in Vestibular Schwannoma Surgery: Results Using the Middle Cranial Fossa Approach

To evaluate surgical results using the middle cranial fossa approach for hearing preservation vestibular schwannoma surgery. Retrospective case review. Tertiary referral academic center. Seventy-three consecutive patients with vestibular schwannoma operated on using the middle cranial fossa approach between February 1999 and February 2005. The tumors were removed via the middle cranial fossa approach with modifications to improve exposure. Standard auditory brainstem and facial nerve monitoring were used. Pre- and postoperative hearing measures and facial function, tumor size, and postoperative complications. Hearing status was categorized into Classes A, B, C, and D as described by the American Academy of Otolaryngology-Head and Heck Surgery "Guidelines for the Evaluation of Hearing Preservation in Acoustic Neuroma, 1995." Thirty-four patients presented with Class A hearing preoperatively. Among patients presenting with Class A hearing, a total of 27 (80%) maintained Class A or B hearing postoperatively. Of these, 21 (62%) remained in Class A, 6 (18%) deteriorated slightly to Class B, and 7 (20%) deteriorated to Class D postoperatively. Twenty-eight patients presented with Class B hearing preoperatively. Of these, 18 (64%) remained in Class B, 3 (11%) deteriorated to Class C, and 7 (25%) deteriorated to Class D. Three patients had Class C hearing preoperatively. Of these, 2 (66%) remained in Class C and 1 (33%) deteriorated to Class D. Eight patients presented in Class D and one of these improved to Class C postoperatively. Overall, 62 patients presented with useful (Class A or B) hearing and 45 (73%) remained in Class A or B. Nineteen patients had tumors larger than 10 mm in greatest dimension and had Class A or B hearing preoperatively. Of these, 11 (58%) retained Class A or B hearing postoperatively. At 4 months or greater follow-up, facial nerve outcome were excellent in 96%: House-Brackmann Grade I in 61 (85%), Grade II in 8 (11%), and Grade III in 3 (4%). There were no Grade IV, V, or VI results on final follow-up. Six (8%) patients developed cerebrospinal fluid leaks. By achieving excellent exposure and using meticulous microsurgical technique, it is possible to resect small vestibular schwannomas via the middle fossa approach, with preservation of hearing at excellent or preoperative levels in the majority of patients, with excellent or satisfactory facial nerve outcomes in 96% of patients.

Eosinophilic dysplasia of the gallbladder: a hitherto undescribed variant identified in association with a "porcelain" gallbladder

Non-mass forming, neoplastic intraepithelial proliferations (dysplasia) represent the most well-accepted precursor lesions to gallbladder adenocarcinomas. They are typically small, localized, grossly unrecognizable lesions that have been identified in the epithelium adjacent to up to 79% of gallbladder adenocarcinomas. Morphologic variants that have been reported include flat, micropapillary, papillary and cribriform. We have recently encountered a morphologically distinctive, previously unreported lesion to which we have applied the designation eosinophilic dysplasia. This lesion was identified in a gallbladder with diffuse mural fibrosis and calcification (porcelain gallbladder). The dysplastic focus was confined to one tissue section, and was comprised of a localized true papilla [i.e with a fibrovascular core], measuring approximately 1.2 mm in greatest dimension and an adjacent, flat, 7-cell epithelial segment. These foci were lined by cells displaying significant nuclear enlargement [1.5–4 times the adjacent benign cells], nuclear pleomorphism, occasional multinucleation, hyperchromasia and nuclear membrane irregularities. Nucleoli were present but inconspicuous. These cells also showed voluminous eosinophilic to granular cytoplasm, such that the overall nuclear-to-cytoplasmic ratio was generally not increased. The cells displayed diffuse and marked nuclear immunoreactivity for p53, and approximately 70% of the cells showed nuclear positivity for Ki-67. The cells were also positive for cytokeratin 7 and were entirely negative for carcinoembryonic antigen (CEA) and chromogranin A. The cells of the adjacent normal epithelium were positive for cytokeratin 7 and CEA, negative for p53 and chromogranin A and showed a Ki-67 labeling index of <10%. Marked overexpression of the p53 protein as well as its high proliferative index are strong arguments in favor of the dysplastic nature of this lesion. However, further studies are required to elucidate its true clinical significance and to determine whether or not its association with a porcelain gallbladder, as noted herein, is entirely fortuitous. However, such studies can only be performed with an increased recognition by practitioners of this distinctive variant.

Repair of Large Nasal Septal Perforations Using Facial Artery Musculomucosal (FAMM) Flap

Nasal septum perforations from surgical submucous resection, septoplasty, blunt trauma, and substance abuse may cause epistaxis, nasal obstruction, discharge, crusting, dryness, pain, and whistling. While small symptomatic perforations are closed with local mucosal flaps, options for closure of large symptomatic perforations are limited. A local pedicled flap, the facial artery musculomucosal (FAMM) flap was studied in patients with large symptomatic nasal septal defects. Patients included in the study had (1) a nasal septal defect measuring at least 20 mm in greatest dimension; and (2) related symptoms of nasal crusting, discharge, dryness, obstruction, epistaxis, pain, or whistling. Six patients (3 males; 3 females) met these criteria and received FAMM flap repair. Outcomes were assessed based on comparison of preoperative versus last follow-up (range, 10-30 months; mean 17 months) assessment of perforation size and symptomatology. Overall discomfort was rated at each time point on a 1-10 scale. Age at time of operation ranged from 21 to 44 years, with a mean of 34 years of age. Causes of septal perforation included blunt trauma (50%), cocaine abuse (33%), and submucous resection (17%). Preoperatively, maximal recorded dimensions of septal perforations ranged from 3.1 to 4.0 cm with a mean of 3.5 +/- 0.4 cm. Symptoms included pain (83%), dryness (67%), crusting (50%), discharge (33%), epistaxis (33%), and obstruction (33%). Three or more symptoms were experienced by 5 patients (83%). Overall discomfort ranged from 6-10, with a mean of 8.4. Postoperatively at last follow-up, all 6 patients (100%) achieved closure of their septal defect (P < 0.001). Overall discomfort score was zero for all 6 patients (100%) (P < 0.0001). Complete symptomatic resolution was also noted among all 6 patients (100%) (P < 0.01). In summary, the advantages of the FAMM flap closure technique were (1) no visible external scar, with minimal donor site morbidity; (2) successful closure of large septal defects (>2 cm) with vascularized tissue in a single stage; and (3) resolution of patient symptomatology.

Unusual case of bilateral adrenal masses in Hong Kong

In May 1996, a 56-year-old man in Hong Kong presented with fever and dry cough and had miliary shadows in bilateral lung fields on chest radiographs. The patient had migrated from Shanghai more than 10 years previously and worked as a cook. Upon admission, he was also found to have diabetes with poor glycaemic control. The clinical diagnosis was miliary tuberculosis (TB), however, all mycobacterial cultures were negative. The man was put on empirical anti-tuberculosis medication. Thrombocytopenia developed shortly afterwards. Bone marrow biopsy revealed foci of epithelioid cell granuloma and normal haematopoiesis, consistent with tuberculosis. Four months later, he presented with persistent bilateral epididymal masses with scrotal pain for 2 weeks. Tender and hardened epididymes were found upon physical examination. The clinical diagnosis was TB epididymitis. Mycobacterial culture of his early morning urine was negative. The empirical anti-TB treatment was lengthened to a total of 18 months until November 1997. In 1998, an incidental finding of bilateral adrenal masses was noted upon computed tomography (CT) of his abdomen. These masses were of soft tissue consistency density with no contrast enhancement in early and delayed phases. CT-guided fine needle aspiration of the right adrenal mass revealed necrotic tissue only in two successive examinations. Ziehl–Neelsen (ZN) stain was negative. Follow-up CT scans indicated no significant interval change in the size of the masses. In 2002, the man complained of insidious onset of left shoulder pain and swelling, as well as knee pain. Magnetic resonance imaging (MRI) and arthroscopy of the left shoulder were performed. MRI revealed rice bodies distending the joint capsule, especially over the subcoracoid and subdeltoid bursae. The clinical diagnosis was TB arthritis and osteomyelitis. Histology of the synovectomy specimen showed oedematous tissue with moderate chronic inflammation and a small focus of granulomatous inflammation. Neither caseous necrosis nor multinucleated giant cell was noted. ZN stain was again negative. The bacterial and mycobacterial cultures of the left shoulder synovial tissue and left knee aspirate were negative. No anti-TB treatment was prescribed. In January 2004, the man presented with significant weight loss. Workup revealed elevated alpha-fetoprotein. A liver tumour was detected, measuring 60640630 mm in greatest dimension and occupying the right lobe of liver, associated with unresolved bilateral adrenal enlargement. A short Synacthen test confirmed normal hypothalamic-pituitary-adrenal function. Partial hepatectomy (central), right adrenalectomy and cholescystectomy were performed. The right adrenal gland measured 55635618 mm in size and weighed 15 g. Serial sectioning showed a nodule with necrotic yellowish material (Fig. 1). Figures 2A and B show the H&E and Grocott stains of the sections of the adrenal lesion, respectively.

Melanocytic Nevi of the Auricular Region

We examined auricular melanocytic nevi to evaluate their architectural and cytologic features. A retrospective analysis of 21 auricular melanocytic nevi was conducted during 3 years. The nevi were evaluated for cytologic atypia, architectural disorder, location of epidermal nests, pagetoid spread, growth pattern (symmetry versus asymmetry), demarcation of lateral borders, and host response (lymphocytic infiltrate and/or lamellar fibroplasia). Eleven cases (52.4%) measured at least 6 mm in greatest dimension and 6 cases (28.6%) were asymmetric. Fourteen cases (66.7%) were ill demarcated. Pagetoid spread was present in 12 cases (57.1%). Ten cases (47.6%) showed moderate to severe cytologic atypia. Nucleoli were prominent in 9 cases (42.8%). None of the cases showed mitoses or apoptotic melanocytes. Auricular melanocytic nevi, like those occurring in the acral, flexural, and genital areas, may exhibit some histologic features commonly found in melanomas. Careful histologic interpretation of these lesions is recommended.

Superficial cervico-vaginal myofibroblastoma: a report of five cases

To describe the pathological and immunohistochemical features of five cases of superficial cervico-vaginal myofibroblastoma (SCVM), a recently described mesenchymal tumour affecting middle-aged and elderly females. The histological features of five cases of SCVM arising in four patients were reviewed including one case which recurred locally 9 years after initial excision biopsy. All cases were immunostained using the streptavidin-biotin technique using antisera to vimentin, smooth muscle actin, desmin, S100 protein, cytokeratin, h-caldesmon, calponin, CD99, CD117 (c-kit), bcl-2, oestrogen receptor and progesterone receptor. The patients were aged from 40 to 71 years (mean 55.2 years). The tumours were situated within the vagina (four cases) and cervix (one case) and ranged from 16 to 45 mm in greatest dimension. One patient had two separate vaginal SCVM. The tumours were characterised by uniform spindle and stellate-shaped cells separated by a collagenous or myxoid stroma. No mitotic activity was identified. Characteristically the tumours were well circumscribed and separated from the surface epithelium by a rim of normal stroma. The initial and recurrent tumours in one patient were similar except for increased stromal collagen in the recurrence. All tumours were immunoreactive for vimentin, desmin, CD34, CD99, bcl-2, calponin and hormone receptors while two tumours showed focal smooth muscle actin expression. There was no expression of S100 protein, h-caldesmon, CD117 or cytokeratin. SCVM appears to be a relatively distinct lesion although there is some histological and immunophenotypical overlap with other mesenchymal tumours, particularly fibroepithelial polyp, leiomyoma and solitary fibrous tumour. As local recurrence developed 9 years after intial treatment in one patient, long-term clinical follow-up would seem appropriate.