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Moderately differentiated neuroendocrine carcinoma of the larynx is morphologically distinct from the classic carcinoid and small-cell carcinoma. It is composed of medium to large polyhedral cells with an insular, trabecular, or acinar growth pattern, variable pleomorphism, and a tendency to metastasize to skin and bone. We describe the clinicopathological features of the tumor in two patients in whom tumor dissemination resulted in death 13 and 33 months after diagnosis. Both tumors occurred above the glottis and metastasized to bone but not to regional tissues. In one case, the diagnosis was confirmed when the aspiration cytological specimen from a rib lesion suggested a neuroendocrine carcinoma resembling medullary thyroid cancer (triangular cytoplasm, double nuclei, and fine red cytoplasmic granules on May-Grünwald-Giemsa staining). Both tumors were originally misdiagnosed as squamous cell carcinoma, as acinic cell cancer, or as suggesting metastasis of melanoma. Immunohistochemistry gave strong reactivity in both for chromogranin A and calcitonin, although the serum level of calcitonin, determined in one case, was normal.

The ovarian hyperstimulation syndrome (OHSS) is one of the most serious complications associated with ovulation induction. Most cases are associated with the use of exogenously administered gonadotropins and, occasionally, clomiphene citrate. Spontaneous OHSS in singleton gestations is extremely infrequent, and only a few cases have been described (1). We discuss a case of severe OHSS resulting from a singleton gestation conceived after spontaneous ovulation. We examined the patient’s hCG/LH receptor gene for a possible mutation to further explain her exaggerated response to normal circulating hCG levels from a singleton pregnancy.

e17017 Background: Positron emission tomography (PET) scanning is widely used in staging of patients (pts.) with head and neck squamous cell cancers (HNSCC). However, the role of PET scan in pts. with early stage disease and clinically negative nodes remains controversial. The purpose of our study was to correlate preoperative PET scan findings in early stage disease with operative pathological findings of neck dissection. Methods: A retrospective review of medical records of all pts. treated at Long Island Jewish Medical Center with T1N0 HNSCC from 2002 to 2008 was undertaken. Institutional Review Board approval was obtained for this study. Eligibility criteria included: clinically staged T1N0, documented pre-operative PET scans and primary surgical management including a neck lymph node dissection as part of initial treatment. Data collected included age, gender, physical examination findings, PET scan results, operative pathology and modalities of treatment. Results: Sixty six pts with early stage T1N0 HNSCC were identified. Twelve of sixty six pts met eligibility criteria for this study. Median age was 61 years (range: 27 to 84 yrs), M:F ratio was 1:1. Primary sites of tumor were: tongue (n = 8) 67%; oral cavity (n = 3) 25%; larynx (n = 1) 8%. Preoperative PET scan was positive at primary sites in all pts (n = 12). Additionally, PET positivity was noted in regional lymph node sites in six of twelve pts. Operative pathology confirmed tumor presence in all primary sites. However, nodal involvement was not found in any pt. Median numbers of lymph nodes dissected were 25 (range:13–34). Based on these clinical data, the calculated statistical parameters for preoperative PET scan in detecting occult neck lymph node metastases were: negative predictive value: 100%; positive predictive value: 50%: specificity: 50%; sensitivity: 0%. Conclusions: The clinical application of PET scans in early stage (T1N0) HNSCC may be limited by its high false positive rate. A high negative predictive value suggests that a negative result can exclude metastatic lymph nodes involvement in this group of pts. with early stage disease. Correlation with SUV values of the PET scans and comparisons between the relative PET avidity of the primary tumors and the nodal uptake are ongoing. No significant financial relationships to disclose.

20544 Background: Cancer-associated thrombosis is a major cause of death in patients (pts) with cancer. The 1-year survival in pts with cancer with VTE is 12% (vs. 36% without VTE). More than 20% o...

Flow cytometric (FCM) DNA ploidy measurements on frozen fresh samples of soft tissue sarcomas were compared with the corresponding analyses on preoperative fine needle aspirates and postoperative formalin-fixed archival tissues from the same tumors. A concordance in ploidy status (diploid versus non-diploid) was obtained for 63% of the fresh tissue-fine needle aspiration (FNA) sample comparisons and for 85% of the fresh tissue-archival material comparisons. The majority of discordances in the fresh tissue-FNA sample comparisons could be explained by FNA sampling errors. In the remaining discordant cases (3 of 27 FNA sample comparisons and 6 of 40 archival material comparisons), sampling errors could not explain the differences in ploidy status. The discordant cases were evenly distributed among the different sampling methods. Method reproducibility was not responsible for the differences in ploidy determinations; tumor heterogeneity may be an explanation for the discrepancies. This study showed that archival soft tissue sarcoma samples are as well suited for DNA ploidy analysis as are fresh frozen tissues.

On potato tuber surfaces at 12° and 20 °C indirect germination of sporangia of Phytophthora infestans was stimulated to levels above those in distilled water. Following indirect sporangial germination, zoospores accumulated preferentially on the lenticels. As the tuber developed and lenticels became more resistant, the number of zoospores accumulating and the proportion subsequently germinating decreased. Differences in the proportion of zoospores germinating on different cultivars were related to cultivar resistance at 20 °C but not at 12 °C. Accumulation of zoospores involved a response to a diffusible stimulus produced by the lenticels.

Over a period of 3 years in Southern Sweden 35 patients were seen with deep-seated limb sarcomas without metastases, 30 of whom were referred before any operation had been carried out. Thirty seven patients with deep-seated benign lesions were referred during the same period because of suspected malignancy. A preoperative diagnosis considered sufficient for a definitive operation was made from the clinical findings, aspiration cytology and radiographic examination, but without open biopsy, in 59 of these 67 cases. The differentiation between a benign and a malignant tumour was correct in all but one. The extent of excision necessary to achieve adequate margins for a soft-tissue sarcoma can often be reduced if open biopsy is avoided, with preservation of function. We conclude that treatment without open biopsy is possible in the great majority of patients with soft-tissue sarcoma.

We reviewed the clinical records and chest radiographs of all patients admitted to our institution between 1982 and 1984 who had pulmonary disease and who were later proved to have acquired immunodeficiency syndrome (AIDS) (95 patients). Diffuse parenchymal lung disease was the most common finding. These infiltrates were usually interstitial and caused by Pneumocystis carinii pneumonia or P. carinii combined with cytomegalovirus infection. Focal, multilobar, interstitial infiltrates were also often seen and usually caused by P. carinii or P. carinii and cytomegalovirus infections. Rarely, well-defined, multiple, interstitial nodules less than 10 mm in diameter were the only or predominant characteristic and were seen only in association with Mycobacterium tuberculosis or Cryptococcus neoformans infections or Kaposi sarcoma. Hilar or mediastinal adenopathy occurred in 17 of the 21 patients with M. tuberculosis or C. neoformans infections. In contrast, only 4% of patients with P. carinii infections presented with these findings. We also found that hilar or mediastinal adenopathy was not significantly associated with peripheral adenopathy. Lung cavitation, pleural effusion, or a normal chest radiograph was uncommon.

SUMMARY Intestinal enzyme activities (dipeptidases and disaccharidases) and mucosal morphology were studied in two groups of paediatric patients: one coeliac group (n=13) and one “suspected cow's milk intolerance” group (n= 5). The patients were studied before and after dietary treatment. 49 children and adults with histologically normal intestinal mucosa served as a control group. Both groups of patients showed a marked secondary decrease in the dipeptidase and the disaccharidase activities. The decrease was more pronounced for the disaccharidase than for the dipeptidase activities, and was reversible on dietary treatment. Among the disaccharidases, the lactase and trehalase activities were most strongly depressed; in the coeliac group, the ala-pro dipeptidase activity was more strongly affected than the other dipeptidases. However, as also the ala-pro dipeptidase activity increased on dietary treatment, this does not provide any clue to the specificity of a hypothetical enzyme whose absence could be responsible for the disease.

Fifty-one percutaneous fine-needle aspiration biopsies guided by selective angiography and 57 by percutaneous transhepatic cholangiography (PTC) were performed in 88 patients. Fifty-two of the patients had a tumor localized to the pancreas and 19 a tumor of the extrahepatic biliary tract. In 17 patients the suspicion of neoplasia was possible to rule out. In 60% of the patients with pancreatic carcinoma and in 53% of the patients with biliary duct carcinoma correct cytological diagnosis was obtained. No false positive results were found. The diagnostic reliability was the same under guidance of angiography as PTC. The experience of the examiner markedly influenced the accuracy of the method. Exact correlation between the cytologic and histologic reports was found in cases where representative material was obtained at the aspiration. None of the 108 punctions was followed by complications. Since the method is harmless and has a high success rate especially in experienced hands it is an important adjunct to the management of pancreatic and bile duct lesions.

The authors review the aid provided and sometimes essential nature of echographic and isotopic studies in cranio-facial trauma when seeking neurological complications -in particular intracranial haematomas and cerebrospinal fluid fistulas. They describe the principles of each of these technics, their indications, performance and limitations. These examinations are simple, rapid and perfectly harmless but must be carried out in specialised departments, which limits their use.

The value of electron microscopy as an adjunct to fine needle aspiration cytology in the preoperative diagnosis of soft tissue tumors was studied in 22 cases. In 19 of these, the aspirated material obtained was adequate for electron microscopy analysis. The aspiration procedure did not damage the cells, and the aspirates were well suited to electron microscopic examination. In many cases this examination enhanced the precision of diagnosis and subclassification. This was the case in two intramuscular myxomas diagnosed as myxoid liposarcomas with light microscopy and in two sarcomalike squamous cell carcinomas diagnosed as polymorphous sarcomas in the ordinary smears.

Histologic verification of the angiographic diagnosis of carcinoma of the pancreas may be achieved by percutaneous, transperitoneal fine-needle aspiration biopsy. The method was used in conjunction with the angiographic procedure in 29 patients with tumors of varying size down to 3 centimeters in diameter. Positive diagnosis was obtained in 22. Complications were not encountered. Since the method is simple and harmless it is recommended whenever histologic verification is desired.

Angiography was performed in ten cases of myeloma (plasmacytoma), of which nine were solitary on admission. All lesions were hypervascular bone tumors with extension of neoplastic growth into adjacent soft tissue. Contrast uptake of the tumors occurred regularly and usually was non-homogeneous. In nearly all cases irregular tumor vessels and early venous drainage was evident with arteriovenous shunting in three. Pathologic-anatomic correlation demonstrated 'tumor vessels' to be newly formed vascular spaces lacking the normal constituents of vessel walls. The contrast uptake presumably was caused by passage of contrast into the newly formed, slit-like capillary vascular spaces. Angiography usually permitted separation of myeloma from benign, hypervascular bone lesions. The procedure proved to be of particular value in indicating definite malignancy, since myeloma was considered initially as the probable diagnosis in only one of the series. It was not possible, however, to differentiate myeloma from other malignant tumors by plain radiography or angiography. Irreversible renal failure occurred in one patient after angiography.

Primary localized non-Hodgkin's lymphomas (NHL) of the thyroid are rare. The data presented are derived from 819 consecutive patients with NHL and six patients with anaplastic thyroid carcinomas of small cell type investigated and treated at our department between 1970 and 1981. The present analyses are based on the 19 patients, who were found to have localized primary thyroid lymphomas. Four of these patients were initially considered to have undifferentiated small cell carcinomas of the thyroid but revealed to be lymphomas at re-examination supplemented with immunohistopathologic staining. Prognosis has been evaluated with regard to initial stage, histopathology according to the Kiel classification and therapy. Median follow-up was 5 years. The crude survival was 77% 5 years after diagnosis. This was not significantly less (4.2%) than the overall-survival in an age- and sex-matched population, despite the majority of patients having tumours which were locally advanced, often with spread to regional lymph nodes, and in many cases a histology showing a high-grade malignancy according to Kiel classification. The excellent prognosis in the current study compared to other studies is probably mainly attributed to more extensive staging procedures. The biologic behaviour supports the hypothesis that these lymphomas represent lymphomas of mucosa associated lymphoid tissue (MALT). According to present results anaplastic thyroid carcinoma of small cell type must be extremely rare.

A visually increased uptake of 201Tl chloride corresponding to a 'cold' (131I or 99Tcm ) thyroid nodule is mostly seen in well-differentiated carcinomas but also often in follicular adenomas. Since a visually increased uptake of 201Tl can be due to an increased initial uptake and/or a delayed elimination, an extended dynamic investigation was performed in patients with well-differentiated carcinomas or with follicular adenomas. Data were collected in a dynamic simultaneous double isotope ( 99Tcm + 201Tl) study up to 50 min after intravenous administration. Adenomas could be significantly separated from carcinomas by the elimination (p = 0.0001), but not by the initial uptake.

A study was performed on baboons (Papio papio) of various hemodynamic and EEG effects of sodium nitroprussiate (SNP), substance with powerful vasodilator action. Three different procedures of drug injection were used: (1) in isolation, either in doses close to those used in clinical practice or in high doses; (2) after neuroleptanalgesia (NLA); (3) after causing vasospasm. With isolated SNP, effects on blood pressure were unstable; in certain cases hypotension could be maintained only with toxic doses. Hypotension was facilitated when NLA had been previously induced. At low doses the cerebral blood flow (CBF) was practically unmodified, whereas at toxic doses it first increased then decreased. In animals under NLA, the CBF drop was only moderate, suggesting persistence of adequate spasm, CBF was significantly improved through SNP. The EEG did not undergo sizeable change at low SNP doses given in isolation; toxic doses always induced alterations with peculiar morphology, but developing only tardily after SNP perfusion was begun. This lag may indicate that hypotensive and toxic SNP effects are dissociated. These alterations suggest that screening of the EEG is necessary during prolonged administration of SNP, e.g., in surgical procedures. Combining NLA and SNP (at low doses) causes EEG deceleration, but no great alteration of the rhythms, as observed during other types of controlled experimental hypotension. Hence, cerebral circulation may be relatively well protected during SNP hypotension.

Nodular fasciitis, the most common pseudosarcomatous proliferative lesion of the soft tissues, is well defined histologically but not cytomorphologically. A histologic and cytologic study of 13 cases of nodular fasciitis is presented. Nodular fasciitis is characterized histologically by proliferating fibroblastlike cells that vary from thin, elongated and spindle shaped with elongated nuclei to plump with one or more large, oval nuclei. The appearance of nodular fasciitis in fine needle aspirations is characterized by the presence of tumor cells varying widely from spindle shaped with long cytoplasmic processes to more plump and cytoplasmatic with one or more nuclei with nucleoli. An attempt to correlate the histologic and cytologic appearances is made. It is stressed that all the cells in nodular fasciitis lack histologic and cytologic signs of malignancy. The differential diagnosis is discussed. The cytomorphology of nodular fasciitis is fairly characteristic, making it possible to recognize these lesions in fine needle aspirates.

A case is reported in which electron microscopy was utilized to make a preoperative differential diagnosis of a soft tissue sarcoma on material obtained by fine-needle aspiration biopsy. The value of electron microscopy as an adjunct to cytologic study of such material is pointed out, as is the suitability of aspirated material for electron microscopic examination.

A study of the preoperative fine needle aspiration cytologies in consecutive patients with primary malignant tumors (203 cases) or benign thyroid tumors (217 cases) showed a sensitivity of 0.57 and a specificity of 0.98. The sensitivity of FNA cytology in medullary and undifferentiated carcinomas was 0.82 and 0.84, respectively; none of these were microscopically misdiagnosed. The sensitivity was only 0.58 for papillary carcinomas (excluding occult carcinoma) and 0.42 for follicular carcinoma. Four reasons for these low sensitivities were identified: tumors missed at aspiration, microscopic misinterpretations, diagnoses of cellular atypia and indeterminate diagnoses. Reevaluation of the false diagnoses once more emphasized the problem of distinguishing follicular adenomas from follicular carcinomas. Microscopically undiagnosed papillary carcinomas were either the result of misinterpretations of the characteristic cytomorphologic features or of the smears being misdiagnosed as showing cellular atypia when papillary formations were missing and only one or two of the other cellular criteria were evident. The specificity of FNA cytology of thyroid tumors was found to be high enough to permit surgical intervention after a cytodiagnosis of malignancy.

An 89-year-old female with a two-year history of a growing tumor of the skin on her left thigh was subjected to fine needle aspiration. Cytologic examination of the aspirate revealed a small-cell carcinoma, and a Merkel-cell carcinoma was suggested. The diagnosis was confirmed by histopathologic and electron microscopic analysis of the removed tumor. The cytologic findings are presented and correlated with the light and electron microscopic pictures of the operative specimen.

Tumour cells may be dispersed into the wound when diagnostic or excisional biopsy is undertaken. This risk is reduced by using fine needle aspiration biopsy. The definitive excision of a soft tissue sarcoma may then be carried out in a more limited manner. In selected cases diagnostic and definitive operation may be combined, accepting the risk of excision of a benign lesion with unnecessarily broad margins. Aspiration cytology could possibly help the surgeon to decide on the extent of the excision. One hundred and nine consecutive patients with soft tissue lesions were referred to the Orthopaedic Oncology Group at Lund in Southern Sweden because of suspected malignancy. Biopsy had not been carried out. Further diagnostic and therapeutic procedures were planned as if aspiration cytology was not going to be used. The procedure was then performed with a fine needle and the cytodiagnosis was used to modify the plan. Sixty-seven tumours were examined histologically. Ten were sarcomas, two metastatic carcinomas and one a malignant lymphoma. The surgical plan was changed after the cytology was known in 33 of the 109 cases. Compartmental or wide excisions which had been planned became unnecessary in 20 patients. No operation was done in 6 patients and in 14 others a more limited excision was carried out. It was possible to avoid planned incisional biopsy in 3 patients with sarcoma.

Sodium nitroprusside (SNP) has been suggested as hypotensive agent in the surgery of cerebral aneurysms. As a preliminary step to neurosurgery, a study of its cerebro-vascular and EEG action had been carried out in 42 papio-papio baboons. On the unanaesthetized analgesic-free animal, doses below 20 mumg/kg/min. induce only a moderate decrease of mean arterial blood pressure (MABP), a slight rise of intracranial pressure (ICP) and a neat fall of cerebro-vascular resistance (CVR) without EEG modifications. Doses above 50 mumg/kg/min. induce a neat fall of MABP with a rise of cerebral blood flow (CBF), of ICP and signs of poisoning with metabolic acidosis and prolonged EEG disturbances. Beyond 90 mumg/kg/min. irreversible hypotension occured accompanied by metabolic acidosis and progressive abolition of cerebral electrogenesis. The hypotensive action of SNP is potentiated by neuroleptanalgesic drugs (phenoperidine and dehydrobenzoperidol). Using this combination marked hypotension was achieved with non toxic doses of SNP (6 to 10 mumg/kg/min.). During those hypotensions cerebral auto-regulation was maintained up to a MABP of 50 mmHg. Deeper brief hypotensions up to a MABP of 25 to 45 mmHg induce a 23% fall of CBF (p less than 0, 05) but without major EEG alterations. During experimental arterial spasms induced by injection of blood in the cisterna magna or serotonin infusion, SNP has a vasodilating action. It induces a significant rise of CBF (p less than 0, 01) for doses between 8 and 19 mumg/kg/min.

At preoperative scintigraphy of 83 consecutive histopathologically confirmed thyroid carcinomas a solitary reduced uptake was observed in 70 per cent. The minimum detectable size was 10 mm for differential carcinomas showing this image, but in the 'screening group' of hereditary medullary carcinoma several scintigrams were considered normal despite a tumour size of 10 to 15 mm. In the imaging of the undifferentiated carcinoma a solitary reduced uptake with disappearance of the entire affected lobe was often demonstrated. Multifocal areas in the dot scintigram representing tumours were often missed at fine needle aspiration biopsy. Computer-processed scintigrams were superior in showing multifocal lesions.

Soft-tissue tumors are a fairly new area for aspiration cytology. As part of the correlation between the cytology and histology in these tumors, a retrospective study of ten intramuscular myxomas was conducted. All of the patients presented with a firm, painless intramuscular mass that was excised with different surgical margins; no recurrences were found at follow-up. The cytologic findings corresponded well with the histologic ones. Droplets of a highly viscous fluid typically characterized an aspirate from an intramuscular myxoma. The fluid was generally not very cellular. The cells had elongated cytoplasm and spindle-shaped nuclei. They varied in size and shape, and cellular atypia was minimal. Aspirates from low-grade myxofibrosarcoma and myxoid liposarcoma presented the main differential diagnostic problems.

In eleven hypertensive patients with renal artery stenosis, the acute renal effects of captopril were investigated using two methods: 1) the Tc99m-DTPA renography with determination of an index of renal perfusion (IP), an index of glomerular filtration (IF) and the ratio of these indices (F/P); 2) the renal hemodynamics obtained by the clearance method using a continuous infusion of I131-hippuran and I125-iothalamate for calculation of renal blood flow (RBF), glomerular filtration rate (GFR) and filtration fraction (FF). The studies were performed before and after captopril treatment. Patients were classified according to the acute response to captopril as responders (R; n = 6) and non responders (NR; n = 5). Results are as follows: (B: basal, C = captopril). (table; see text) These data confirm that captopril produced a significant decrease in F/P and FF in R whereas these indices did not change in NR; it was found that IF and GFR decreased in R whereas IF increased and GFR did not change in NR; a significant correlation was observed between delta IF and delta GFR in R (r = 0.834, p less than 0.05). These results indicate that 1) data obtained before and after captopril by renography and by clearance methods are in good correlation either in Ror in NR patients; 2) Captopril test including renography or renal hemodynamic measurements is useful for selection of R patients.

This paper shows how a well planned computer system can transform a practice's programme of prevention and surveillance, for long the Cinderella subjects in our Health Service. It was not necessary to employ specially trained staff to operate the computer and our receptionists adapted quickly and successfully: in fact, a new and interesting job coordinating the new routines has evolved which will include the preparation and presentation of a wide range of practice statistics. After initial hostility the computer has been accepted by the staff and its ability to increase the efficiency of the practice at all levels is now well recognised. Attention to the manual records, including updating summary sheets, was a vital part of our transition, and satisfactory office routines for recording all information daily is as essential. Since the computer was introduced the accuracy of our filing has improved dramatically. Rates of uptake for all immunisations and cervical cytology examinations are much better and the surveillance of various groups, whether by health visitors, nurses, or doctors, is no longer haphazard. The costs are within the scope of any practice, but positive encouragement by government (probably financial) would make acceptance of computers more likely. This would certainly encourage practitioners to take the initiative in prevention and surveillance, thereby ensuring that general practice remains the focus of a patient's overall care in the next decades.

The clinicopathology of Merkel cell carcinoma (MC) has been evaluated in 17 patients, and its outcome and clinical management in 14 of these. The histopathologic diagnosis was confirmed by electronmicroscopy and/or immunohistopathology. The location of the primary lesions demonstrated a predilection for the skin of the face and the extremities. The primary treatment usually consisted of a wide excision only. Four out of five patients with MC of the face suffered from local and/or nodal relapses, in contrast to only one out of seven patients with primary lesion on the extremities. The three patients treated for local recurrences and/or regional node metastases were alive and disease-free 22-72 months after recurrences. Three patients developed distant metastases. Two of these died within 4 months after initial diagnosis. One patient completely responded to chemotherapy. The high frequency of local recurrences would justify an excision with generous margins, except when the tumour is close to a vital structure. Radiotherapy could in these cases obviate the necessity for extensive operations. If the primary lesion is located on an extremity, regional lymphadenectomy seems only to be necessary whenever nodal involvement is suspected. Node dissection is also recommended for suspected nodes in the face or on the neck, but the guidelines for elective node dissections in these sites are not obvious since the results of salvage therapy were excellent and the location of relapses unpredictable.

An increase concentration of pertechnate in the choroid plexus was demonstrated in 21 patients pretreated with tin pyrophosphate injected intravenously 24 hours before the examination. Using this technique, the choroid plexus are seen quite clearly, giving indirectly a picture of the intracerebral ventricles. A dynamic study was carried out in 12 patients, 3 of whom had abnormalities of the cerebrospinal fluid circulation demonstrated by isotope cisternography. The results obtained were characterised by a typical diphasic curve with variations in the pathological cases.