Polypoid Formations Research Articles

Case report: juvenile paracoccidioidomycosis with intestinal involvement

Introduction: Contact of Paracoccidioides sp. with the human organism presents in a variety of clinical forms of the disease. Intestinal clinical manifestation is found in 10 to 30% of cases, commonly in juvenile form. This case report seeks to describe a patient with juvenile paracoccidioidomycosis with atypical intestinal involvement. Case report: A 14 years old woman with an updated vaccination schedule and no reports of chronic diseases, allergies or continued use of medications, presented a diarrheal condition that was characterized by pasty stools, where episodes became gradually more intense, associated with episodes of hematochezia, retroauricular lymphadenopathy on the right, as well as shivering and fever. A colonoscopy revealed multiple polypoid formations, ulcerations and friability throughout the colon. After biopsy results, the diagnosis of Paracoccidioidomycosis with intestinal involvement was established. Due to the wasting syndrome, anemia and persistent diarrhea, the patient was hospitalized for blood transfusion and intravenous treatment with conventional Amphotericin B. Discussion: Unlike what was presented by the patient in this case, involvement of the gastrointestinal tract is uncommon in paracoccidioidomycosis. This disease presents a range of clinical manifestations, which makes diagnosis difficult. Since this type of infection is not always considered, it may result in underdiagnosed cases, especially in women and young adults. The prognosis depends on the initial severity of the disease, the presence of comorbidities and the treatment used. Conclusion: Especially for the intestinal form, earlier treatment will better the results. The disease has a good chance of effective treatment using antifungal therapy.

Incidental findings of the nose and paranasal sinuses in orthodontic patients in the age of development: a retrospective study on CBCTs.

Nowadays, the use of CBCT in orthodontics and paediatric dentistry is constantly increasing. Since it allows a precise 3D visualisation of the entire head, CBCT can be used to identify alterations and pathologies of the jaws, but also of the sinonasal complex. Despite that, literature lacks studies focusing on the sinonasal complex of healthy orthodontic paediatric patients. Therefore, the aim of this cross-sectional retrospective study is to analyse the prevalence of incidental findings and anatomic variations of the nose and paranasal sinuses in orthodontic patients in the age of development. The 61 CBCTs that respected all inclusion criteria (patient's age under 15 years old and CBCT scans showing the entire sinonasal complex, data in DICOM format) were searched for: nasal septum deviation, Onodi cells, Haller cells, concha bullosa, sinus underdevelopment, sinus mucosal thickening, sinus cysts or polypoid formations. CBCTs were evaluated by two different orthodontists and their findings were then compared and statistically analysed. Considered the high prevalence of incidental findings, prescription of a CBCT to paediatric patiens seems crucial in order to to detect conditions that would require referral to a specialist.

Gallbladder polyps: diagnosis and treatment tactics (literature review)

Gallbladder polyps are an elevation of the mucous membrane that protrudes into the lumen of the gallbladder cavity. Pathology, according to world literature, occurs with a frequency of 0.3% to 13.8%. Currently, the diagnosis of polypoid formations of the gallbladder is based on the routine use of ultrasound, without further clarifying research, which often leads to errors in treatment tactics. In the domestic literature, there are very few studies on this topic, despite the relevance of this area.

Эндоскопические и морфологические признаки хронического рецидивирующего папилломавирусного цистита

INTRODUCTION Chronic recurrent cystitis (CRC) is a common disease in the female population and a serious medical problem. There are not enough data about etiology of this desiase and effective treatment. OBJECTIVE To increase the accuracy of the differential diagnosis of bacterial and papillomavirus chronic recurrent cystitis. MATERIALS AND METHODS Analysis of endoscopic and morphological diagnostic methods of 118 patients with CRC, which, depending on the etiological factor, were divided into two groups. Group I (n=65) patients with CRC of HPV etiology and Group II (n=53) - CRC of bacterial etiology (E. coli). All patients were examined according to the EAU and RSU recommendations, and an endoscopic examination of the bladder (cystoscopy) was additionally included, followed by morphological examination of biopsy specimen of the urinary bladder. RESULTS The endoscopic picture of bacterial CRC usually is caused by hyperemia of the mucous membrane of the bladder, hyperemia and injection of vessels with the participation of (small-puncture/diapedesic) hemorrhages without signs of proliferative changes. The endoscopic picture in papillomavirus CRC in all patients presented by focal or diffuse, slightly elevated, exophytic, often polypoid formations of a whitish or whitish-gray color, usually localized in the Leto triangle. Morphological analysis of biopsy tissue of the urinary bladder in patients with bacterial cystitis in the mucous and submucous layer showed edema, thickening of the urothelium, capillary abundance, inflammatory infiltration, represented by lymphocytes, plasma cells and leukocytes, among which neutrophilic macrophage leukocytes were predominant. Morphological analysis of the bladder mucosa in all examined patients with signs of HPV-related lesions showed a thickening of the urothelium, squamous metaplasia of the urothelium, chronic inflammation, microcirculatory vascular reaction and edema. An important distinctive pathomorphological sign of HPV within urinary bladder was the presence of koilocytic transformation of urothelium cells due to the cytopathic effect of the virus. CONCLUSIONS Papillomavirus CR has characterized by an infectious-inflammatory process in the bladder paries, with lymphocytic-plasmatic infiltration and coylocytic transformation of the urothelium.

Gallbladder polyps: modern approaches to diagnostics and treatment

Gallbladder polyps are an elevation of the mucous membrane that protrudes into the lumen of the gallbladder cavity. Their prevalence in the general population varies from 0.3 to 13.8%. According to the modern classification, polyps of the gallbladder are divided into benign non-tumor, benign tumor and malignant tumor polyps. A review of modern literature presents cohort and randomized controlled trials, including those summarized in meta-analyzes and systematic reviews, suggesting that the dominant form of polypoid formations of the gallbladder are cholesterol pseudo-polyps with no malignant potential associated with impaired cholesterol metabolism, often combined with gallbladder cholesterosis, metabolic syndrome and cardiovascular morbidity. Evidence is building up on the effectiveness of ursodeoxycholic acid for controlling components of the metabolic syndrome and cardiovascular risks. Ursodeoxycholic acid preparations may become promising for the management of cholesterol polyps.

Estudo anatomopatológico dos pólipos endometriais diagnosticados por histeroscopia

A incidência de malignidade em formações polipoides do endométrio tem sido estudada recentemente em diversos países, encontrando-se entre 0 e 4,8% na maioria dos trabalhos. A crescente utilização da ultrassonografia transvaginal mesmo em mulheres assintomáticas aumentou a frequência desse diagnóstico em nosso meio. Diversos estudos recomendam a exérese e a avaliação histológica de toda a lesão polipoide visualizada no exame histeroscópico para exclusão de malignidade, porém essa abordagem não é consensual, sobretudo quando as pacientes são jovens ou assintomáticas. O presente estudo avaliou 458 resultados de exames anatomopatológicos de pacientes com diagnóstico histeroscópico de pólipo endometrial, admitidas em laboratório de patologia geral. O diagnóstico histeroscópico confirmou-se em 79,9% dos casos (76,0–83,3%, IC95%) e a prevalência do adenocarcinoma foi de 5,25% (3,7–7,9%, IC95%) em todos os exames. As atipias celulares foram identificadas em hiperplasias glandulares simples ou complexas em 1,9% do total de pólipos endometriais (0,9–3,8%, IC95%). A idade maior ou igual a 51 anos comportou-se como variável fortemente associada à maior prevalência de lesões malignas e pré-malignas, que nesse grupo etário representou 12,2% dos diagnósticos. Comparando-se ao grupo de pacientes com idade entre 41 e 50 anos, a razão de prevalência foi de 2,96, com odds ratio de 3,23. A prevalência de 6,99% de lesões pré-malignas e malignas encontrada na população geral do estudo em pauta justifica a preconização da exérese histeroscópica e o exame histopatológico de todo achado na cavidade endometrial, independentemente do tamanho ou do aspecto macroscópico benigno que o pólipo possa aparentar.

Nasal and Laryngeal Rhinosporidiosis in Horses Treated with Electrocautery

Background: Rhinosporidiosis is considered an endemic disease in some countries and can affect several species of animals, among them, also equines. In this specie, although the nasal cavity is the most common site of infection, in some cases, it could also be spotted in the larynx region. The present study had as an objective to describe two cases of rhinosporidiosis in horses, one of them nasal and the other in the laryngeal area.Cases: Horse 1. A 12-year-old male Standardbred was sent to the veterinary hospital for the resection of the formation presented in the mucocutaneous junction of the left nostril. During the physical exam, a red mass of a moderately consistency, with an irregular, verrucous, pedunculated and ulcerated surface was observed, measuring approximately 2 centimeters in diameter. The surgical procedure for the resection of the mass was done through the use of the electrocautery technique, with the animal sedated with a romifidine dose of 0.08 mg/kg, a butorphanol dose of 0.04 mg/kg and a local anesthesia of 2% lidocaine. Eight months after the surgical procedure, the animal returned to the hospital and the presence of three new masses was noted in the same nostril, around the region where the extracted mass used to be found and they resembled the previous lesions. The horse’s owner didn’t authorize a new surgery or a new histopathological exam of the lesions. Horse 2. The other case refers to an asymptomatic 15-year-old male mixed breed. During a routine gastroscopic exam, the presence of several reddish coloration nodular and polypoid formations of irregular surface was observed in the larynx. Only one formation in the dorsal portion of the pharynx was observed. During the macroscopic exam, it was observed heterogeneously formation with a grayish-white color and soft consistency aspect. The surgical procedure for the resection of the mass, also through electrocautery, was performed with the animal, previously sedated with a detomidine dose of 0.01 mg/kg and a butorphanol dose of 0.02 mg/kg through intravenous. The contact plate of the electrocautery was fixed to the left side of the animal's neck. After the introduction of the endoscope through the nostril and advancing to the pharynx and larynx, lidocaine 2% without a vasoconstrictor was sprayed in the region. The polyps were individually wrapped by the polypectomy loop, passed through the endoscope operational channel and, at this time, the electrocautery was activated. After the treatment, periodical return appointments were made for the next two months. During the fourth appointment, the animal presented, in the endoscopy, a relapse of a few formations which were, again, removed with electrocautery. The histopathological exam in both cases was characterized by the presence of sporangia that was distributed homogeneously across the submucosal blade interspersed with mild to moderate mixed inflammatory infiltration composed predominantly of lymphoplasmic cells, followed by neutrophils and macrophages, as well as some hemorrhage area and the presence of macrophages with hemosiderin. These histopathological findings were consistent with rhinosporidiosis.Discussion: Rhinosporidiosis in horses, although rare, must be considered not only in cases of nasal formations, their most common form, but also in laryngeal cases, while the use of electrocautery is an efficient technique in the removal of the lesions, allowing for a good tissue healing and no postoperative complications. Nevertheless, follow-ups after treatment is always recommended to identify possible relapses.

THE GIANT INVERTED PAPILLOMA SCHNEIDER WITH GERMINATION IN THE ACNE SINUSES AND NASOPHARYNX

Inverted transitional cell papilloma (Schneider papilloma), a rare benign tumor, accounts for about 0.5 % of all neoplasms of the nose. Usually unilateral, recurrences of the tumor can occur after 5-10 years. In about 5% of patients, an inverted transitional cell papilloma is able to turn into cancer after a long-term benign course. These tumors have a destructive growth, recur and malignize. The article presents a case from clinical practice. The patient was admitted with a diagnosis of right-sided chronic polypous sinusitis. On examination, the right half of the nose is filled with polypoid formations, and in the posterior rhinoscopy, formations similar to a giant choanal polyp are determined. The peculiarity of education in the nasopharynx was hilly, lobed surface, so it was decided to carry out nasopharyngeal endoscopy through the left half of the nose for better visualization and taking a biopsy. The result of histological examination is an inverted transitional cell papilloma. The patient underwent a CT scan of the paranasal sinuses: the right half of the nasal cavity is filled with a soft tissue density mass formation, which prolapses into the right maxillary sinus, and is accompanied by the destruction of bone trabeculae and protrusion of the labyrinth walls and fills the right frontal sinus. Under intravenous combined anesthesia with tracheal intubation, a sinus surgery was performed according to Denker. Tumor formation removed as a single unit. The right half of the nose, the cavity of the maxillary and ethmoid sinuses and nasopharynx form a single cavity. There were no complications during the operation. Remote tumor was sent for histopathological examination. The result of histopathological examination of a remote tumor is an inverted papilloma. The peculiarity of this clinical case is the rarity of the pathology, the gigantic size of the neoplasm, the germination of the inverted papilloma in the maxillary, ethmoid sinuses and nasopharynx, removal of the neoplasm as a single unit, minimal blood loss during the operation, the absence of complications.

Hymenal polyps in two infants

Pathological conditions of the hymen are rare in everyday medical practice. Hymenal polyps are polypoid formations originating from the hymenal rim and are benign and disappear spontaneously within a few weeks of onset. We report two cases of hymenal polyps in two infants.

P14.08: Focal endometrial pathology, ultrasound, hysteroscopy and histology: what is the correlation between them?

To evaluate the accuracy of gynecological ultrasound for focal endometrial pathology, using data of ultrasound, hysteroscopy and histology. We defined focal pathology on ultrasound as the presence of polyp, myoma or unspecified focal pathology. We studied all women with suspicion of focal endometrial pathology in gynecological ultrasound between January 2013 and December 2014. Of all these women, we went to see how many had hysteroscopy and/or histology results and then we studied the correlation between the findings. There were 804 women with abnormal endometrial findings in ultrasound, of which 352 with focal pathology. The age of women in this last group varied between 20 and 87, with an average of 55.1 years. 179 women were post-menopausal. The endometrial thickness varied between 4 and 48 mm. 164 women were submitted to hysteroscopy. In 2 cases the procedure was abandoned for uterine perforation and in 20 cases there was no focal pathology. There were 4 cases of synechiae, 5 septums, 13 uterine myomas, 119 uterine polyps and 1 case suspected of malignant neoplasia in a polypoid formation. There were 3 confirmed cases of malignancy, all present in polypoid formations. 16 women were directly submitted to hysterectomy. 7 had uterine myoma and the others had no focal pathology. In this sample, we obtained a positive predictive value of ultrasound for focal endometrial pathology of 82.7%. We could not find any cut-off value of endometrial thickness below which there is never a focal pathology and above which there is always pathology. All women with endometrial malignancy had an endometrial thickness above 5 mm. Our women with suspected focal endometrial pathology on gynecological ultrasound had a probability of actually having an abnormal finding of 82.7%. The endometrial thickness value did not allow us to distinguish women with and without focal pathology, however no woman with an endometrium with less than 5 mm had malignant focal pathology.

A left atrial calcified amorphous tumor

In this article, we present a 82-year-old female case without any previous history of heart disease diagnosed with a hyperdense mass originating in left atrial side of the interatrial septum on echocardiography. The patient was scheduled for surgery. Left atrium was entered through the interatrial groove. The tumor was found attached to the interatrial septum. It was macroscopically creamish-yellow colored, 20x10 mm in size and solid in texture. It was totally resected from its attachments to the interatrial septum. Light microscopy showed polypoid formations with prominent papillary structures including scattered hyalinized areas and large areas of calcification. The mass was pathologically diagnosed as cardiac calcified amorphous tumor. She was discharged under medical treatment on seventh day after surgery.

ENDOSCOPIC TREATMENT OF EPITHELIAL ESOPHAGEAL AND GASTRIC NEOPLASIAS

Aim. To optimize endosurgical treatment of the epithelial esophageal and gastric neoplasias. Materials and methods. The results of treatment of 41 patients with polypoid formations of abdominal esophagus and stomach on the wide basis including 16 patients diagnosed hyperplastic polyp with moderate and severe dysplasia, 23 - adenoma with moderate and severe dysplasia, 1 - low-differentiated microcarcinoma in the hyperplastic polyp with moderate dysplasia, 1 - low-differentiated microcarcinoma in the tubular adenoma were studied. Results. Examination of patients with epithelial esophageal and gastric neoplasias by means of videoesophagogastroduodenoscopy with biopsy of tissue and mucosa in the region of its basis, chromoscopy and endosonography permits to exclude expansion of the process to the submucosal and muscular layers and to determine the possibility of radical endoscopic treatment. In case of localized dysplasia of gastric endothelium, mucosal resection with formation of a false stalk and welding of stalk-forming tissues can be considered as an effective measure for prevention of malignant transformation and in case of microcarcinoma - a radical variant of treatment.

Comprehensive study of the endometrium of women with reproductive disorders, and chronic endometritis

UDC: 618.14-002 The study of the endometrium and the development of new methods of rehabilitation therapy for women with reproductive disorders is important issue in modern obstetrics. Violations of the proliferative activity of the endometrium, the presence of persistent infection and changes in local immunity are the main causes of obstetric and perinatal complications (Adamian and Kulakov, 1997; Donders, Van Bulek, Caudron et al., 2000; Vikhlyaeva, 2002). The aim of this work was studying the hysteroscopic endometrium and its integrated study (immunological, histological, bacteriological and PCR) of 84 patients with a violation of the reproductive function to determine the role of persistent mycoplasma infection. Endoscopic exploration of the uterine cavity was carried out using the “KARL STORZ” (Germany). We used saline solution as the liquid medium. After removing the polyps, polypoid formations and doing endometrial sampling for the immunological, histological, bacteriological and PCR study, we carried out a hysteroscopic control research, which made it possible to evaluate the effectiveness of the operation. A visual study of the uterus showed that the endometrium had no pathology and corresponded to the phase of the menstrual cycle in 26.2% of cases and other 73.8% revealed various pathologies of the endometrium. Herewith, the most common pathology of endometrium were various hyperplastic processes (in 70.9% of cases - glandular and glandular-fibrous hyperplasia, various types of polyps). We noticed the endoscopic differences between the fibrous and glandular polyps, which were appearing in different sizes and shapes of polyps localization. With hysteroscopy, fibrous polyps were often determined as a single pale formation of round or oval shape, with a small size (0.5 cm). Most polyps were located in the bottom of the uterus, near the ostium of the uterine tubes. Glandular polyps, in contrast to fibrous were larger in size (0.5 to 5-6 cm) and in most cases were multiple. The colors of the polyps were pale-pink and gray-pink; the tip of the polyp - a dark purple or blue-purple color. We spotted vessels in the shape of capillary net on the surface of the polyp. The symptoms of chronic endometritis were characterized by increased vascular pattern, edema and focal hyperemia of the endometrium, which were noted in 19.04% of cases. In about the same percentage of cases we revealed endometriosis of the uterus - 2.4% and intrauterine adhesions - 2.4%. With adenomyosis, the endoscopy took form of the “eyes” of dark-purple color on the background of relief of the uterine walls. Upon detection of intrauterine synechia: the uterus is divided by vertical spikes of whitish color, the volume of the cavity is reduced.

Lymphovenöse Shunts und Thromboide bei Harnstauungsniere

This case of urinary obstruction with short anamnesis illuminates the early tissue reaction to urine extravasation, especially the Tamm-Horsfall protein. The latter becomes organized in the manner of a foreign body substance and drains via ectatic renal lymph vessels and reopened lymphovenous shunts into the intrarenal venous system. Polypoid formations (thromboids) with or without vessel obliteration appear to result in a clinical course of severe renal impairment.

Malakoplakia of the Gastrointestinal Tract: Prevalence and Clinicopathological Associations

Purpose: Malakoplakia (MP) is a rare granulomatous condition thought to result from the insufficient killing of bacteria by macrophages; it is of uncertain clinical significance and can occur at any tissue site. It may be focal or widespread, involving multiple organs. Gastrointestinal MP has been described in association with a variety of conditions such as ulcerative colitis, diverticulitis, adenomatous polyps, and carcinoma. It has been reported to cause rectal bleeding, diarrhea, abdominal pain and simulate polyps or masses. This study reports on the clinicopathologic associations in a series of 8 patients. Methods: This study was conducted at Caris Life Sciences, a specialized gastrointestinal laboratory receiving specimens from outpatient endoscopy centers across the US. Biopsies are interpreted by a group of gastrointestinal pathologists who have achieved a high level of diagnostic agreement by using uniform diagnostic criteria and terminology. We analyzed electronic data from the Caris database, which includes demographic, clinical, and endoscopic information for each patient, the site of origin and the histopathologic report for each biopsy. From a series of over 600,000 patients who underwent upper or lower endoscopies with mucosal biopsies between January 2009 till May 2010, we extracted data for all patients who had a histopathologic diagnosis of MP. Results: There were 8 patients with MP, 7 women and one man, aged 26 to 85 years. Two patients were from LA, and one each from NC, PR, FL, AZ, MD and CA. MP was detected exclusively at a single site in the colon in all cases. No patient had MP in the upper gastrointestinal tract or the small intestine, and none had evidence of diffuse disease. MP was detected in lesions submitted as polyps in all cases: 3 polyps were from the cecum, 3 from the rectum, and one each from sigmoid and ascending colon. Reasons for colonoscopy were: screening for colorectal cancer in 4 patients, bowl habits changes (2 patients), diarrhea (1 patient), and abdominal pain (1 patient). Von Kossa and iron stains showed the diagnostic Michaelis-Gutman bodies in all cases. No previous history of infection, immunosuppression, or other relevant condition was reported in any of the patients. Conclusion: This series confirms that MP is an extremely rare condition, with a prevalence of <0.8 in 100,000 patients with gastrointestinal mucosal biopsies. MP was restricted to the colon in all cases. Clinical presentations were varied: four patients were asymptomatic and the others had changes of bowel habits that may not necessarily be related to MP. All cases were detected in polypoid formations. No MP was identified in “classic” cold climate states/territories.

3038: 3D multiplanar images of the gallbladder pathology

Ultrasonography must be a routine examination of any gallbladder problem and 3D images has a significant role in differentiating the gallbladder pathologies. 3D will help to obtain a fast and accurate diagnosis of cases and help for giving an appropriate treatment or preventing severe life threatening complications and consequences. Ultrasound has been the first resource for studying this organ and the possible pathologies. The data to obtain is: location, dimensions, definition between a diffuse or localized process, wall width dimensions, internal gallbladder valuation and surrounding or related structures impact. This paper shows different images of cuts and volumes in normal conditions and of different alterations like acute and chronic inflammatory processes, eelworm, lithiasis, polypoid formations, wall alterations and tumoral mass. When 3D Ultrasound is unavailable, it can be partially compensated by regular ultrasound. Still, the most important step is to make 3D ultrasound a routine study for the gallbladder.

Nephrogenic Adenoma of the Urinary Bladder

The nephrogenic adenoma (NA) is a benign metaplastic lesion of the urothelium and is attributed to chronic irritation of the mucosa, by injury, infection, stone disease or intravesical instrumentations. We present our experience on this morbid entity, its clinical appearance in the urinary bladder, its frequency and relapses. Furthermore we reviewed the related recent literature and focused on its potential to neoplastic degeneration and the value of the new diagnostic modalities. Four patients with NA of the urinary bladder are presented. The papilloid or polypoid formations observed by the cystoscopy were identified after the TUR, as NA of the urinary bladder. Their mean follow-up was 3.5 years. Remission of the symptoms was observed after TUR in all patients. Three out of four patients presented 1-7 relapses, while in one case, after seven NA relapses, a urothelial carcinoma of the bladder was diagnosed. Unlike histological features, the clinical - endoscopic characteristics of NA are non-specific. Even if it is not definitely considered like a premalignant condition, NA has to be followed up frequently and long lasting, because of its high recurrence rate. The combination of Cytology, Flow cytometry, DNA image analysis and Fluorescence in situ hybridization of bladder washings or voided urine, are of high value in monitoring NA of the urothelium.

Nephrogenic adenoma of the urinary bladder

The nephrogenic adenoma (NA) is a benign metaplastic lesion of the urothelium and is attributed to chronic irritation of the mucosa, by injury, infection, stone disease or intravesical instrumentations. We present our experience on this morbid entity, its clinical appearance in the urinary bladder, its frequency and relapses. Furthermore we reviewed the related recent literature and focused on its potential to neoplastic degeneration and the value of the new diagnostic modalities. Four patients with NA of the urinary bladder are presented. The papilloid or polypoid formations observed by the cystoscopy were identified after the TUR, as NA of the urinary bladder. Their mean follow-up was 3.5 years. Remission of the symptoms was observed after TUR in all patients. Three out of four patients presented 1-7 relapses, while in one case, after seven NA relapses, a urothelial carcinoma of the bladder was diagnosed. Unlike histological features, the clinical--endoscopic characteristics of NA are non-specific. Even if it is not definitely considered like a premalignant condition, NA has to be followed up frequently and long lasting, because of its high recurrence rate. The combination of Cytology, Flow cytometry, DNA image analysis and Fluorescence in situ hybridisation of bladder washings or voided urine, are of high value in monitoring NA of the urothelium.

CENTRAL PRECOCIOUS PUBERTY IN MULTISYSTEM LANGERHANS CELL HISTIOCYTOSIS: A Case Report

The authors describe a girl with multisystem Langerhans cell histiocytosis (LCH) who developed central precocious puberty (CPP). At the age of 19 months she presented with otorrhea and polypoid formations in the ear canal; polyps were removed and LCH suspected. She subsequently developed diabetes insipidus with a documented lesion of the pituitary stalk; she received chemotherapy and began therapy with 1-desamino-8-D-argininevasopressin. Growth hormone deficiency was diagnosed at the age of 4.4 years and GH replacement therapy started. The patient has been off therapy for LCH since the age of 6. Signs of pubertal development appeared at 7.5 years (bone age 8 years) and gonadotropin-releasing hormone analog (GnRHa) treatment was started. During the observation period she developed central hypothyroidism. Development of CPP during LCH is extremely rare; to the authors' knowledge, no patient has been described so far. The authors believe that CPP was secondary to LCH and did not represent a casual finding, even in the absence of hypothalamic-pituitary axis involvement. The presence of preceding lesions producing excessive cytokine levels, with damage on the neurosecretory apparatus that inhibits the GnRH pulse generator, represents the most intriguing hypothesis. The possibility of CPP development should be considered during the follow-up of these patients.

The diagnostic accuracy of outpatient miniature hysteroscopy in predicting premalignant and malignant endometrial lesions

ObjectiveTo determine the accuracy of outpatient miniature hysteroscopy in the diagnosis of premalignant and malignant endometrial lesions.DesignA prospective cohort study (1996–1997).SettingMinimal access surgical training centre in a large teaching hospital.MethodsOutpatient hysteroscopy and endometrial sampling was carried out on 248 patients with abnormal uterine bleeding. Any patients unable to undergo these outpatient procedures were admitted for a formal inpatient hysteroscopy and curettage. Test performance characteristics were computed for hysteroscopy, comparing its findings with the histological diagnosis which served as a ‘gold standard’.Main outcome measuresThe estimate of the accuracy of the hysteroscopic findings was based, for binary results, on sensitivity, specificity and predictive values. For multilevel results, the diagnostic accuracy was computed using likelihood ratios (LRs). With a normal hysteroscopy result, an LR of &lt;1 indicated a decreased probability that a premalignant/malignant lesion was present, whereas with an abnormal hysteroscopy result, an LR of &gt;1 indicated an increased probability that such a lesion was present.ResultsHysteroscopy revealed features of normal endometrium in 228 women, of whom 12 were found histologically to have premalignant hyperplasia/cancer. Hysteroscopic features of premalignant/malignant endometrial lesions were suspected in 20 patients but the diagnosis was confirmed histologically in six cases only. This amounted to a sensitivity of 33.3% (95% confidence intervals (CI) 14.4–58.8), a specificity of 93.9% (95% CI 89.8–96.5), a positive predictive value of 30.3%. (95% CI 12.8–54.3), and a negative predictive value of 94.7%. (95%CI 90.8–97.1). Analysis using likelihood ratios revealed that for a normal hysteroscopy the LR was 0.7 (95% CI 0.5–0.9). The LR was 1.9 (95% CI 0.5–6.6) when there was intermediate abnormality (increased endometrial thickness, abnormal vascularization, polypoid formations, mamillations and cerebroid irregularities). The LR was 51.1 (95% CI 7.9–326.9) when there was definite hysteroscopic abnormality (intermediate abnormality features associated with irregular polylobular friable excrescences with necrosis or bleeding).ConclusionThe probability of the presence of a premalignant/malignant lesion is not particularly altered by the finding of normal hysteroscopic appearances or of intermediately abnormal features. However, if the hysteroscopic findings are definitely abnormal, the probability of there being a premalignant/malignant lesion is substantially increased. Normal findings at hysteroscopy are not conclusive and do not eliminate the need for endometrial sampling as they are not a substitute for benign findings on histological investigation.