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The TNM staging system was developed by the American Joint Committee on Cancer (AJCC) to be a data-driven, evidence-based cancer staging system providing an accurate prediction of outcome. Although once [...], * Context.--The American Joint Committee on Cancer's Cancer Staging Manual 7th edition defines pericolonic tumor deposits (TDs) as discrete tumor foci in pericolic fat showing no evidence of residual lymph node (LN). This definition relies on subjective features rather than size (5th edition) or shape (6th edition) and introduced the category N1c. Although typically straightforward, metastases are encountered for which the distinction between LNs and TDs is unclear. For data to be meaningful, agreement on distinguishing features between positive LNs and TDs is needed. Objectives.--To assess agreement among gastrointestinal pathologists evaluating difficult metastases and to report the distinguishing features they found helpful. Design.--Twenty-five tumor metastases from right-sided colonic adenocarcinomas were selected in which the distinction between positive LNs and TDs was challenging. Virtual slides were reviewed by 7 gastrointestinal pathologists. A list of features potentially helpful in differentiating positive LNs and TDs was ranked for usefulness by each pathologist. Every metastasis was diagnosed as positive LN or TD. For each case diagnosed as positive LN, reviewers were asked to list every feature used in diagnosis. Results.--Complete agreement was found for 11 of 25 metastases, 5 positive LNs and 6 TDs (statistic, 0.48; 95% confidence interval, 0.28-0.67). Top-ranked features included round shape, peripheral lymphocyte rim, peripheral lymphoid follicles, possible subcapsular sinus, residual LN in surrounding fibroadipose tissue, and thick capsule. The top used features were similar among reviewers. Conclusions.--Significant agreement on positive LNs and TDs in difficult colonic adenocarcinoma metastases was found among evaluators, but inconsistency remains. Round shape, peripheral lymphocyte rim, peripheral lymphoid follicles, possible subcapsular sinus, residual LN in surrounding fibroadipose tissue, and thick capsule were most often used to aid in diagnosis. (Arch Pathol Lab Med. 2014; 138:636-642; doi: 10.5858/arpa.2013-0166-OA)

Although stroke is by no means common in pregnancy, the risk of stroke for a woman rises about 13-fold when she is pregnant. The majority of strokes occurring during pregnancy involve blockage of an artery in the brain. There have been several cases of spasms of cerebral blood vessels associated with pregnancy, but in all these cases, the patient had clear signs of preeclampsia. (This is a complication of pregnancy involving, among other things, a pathological elevation of blood pressure.) A case has now been seen in which a fatal vasospasm developed in a 27-year-old woman in the period after giving birth. The patient developed a headache after going home on the fourth hospital day. Thirteen days after giving birth, the patient developed a transient weakness which affected the left side of her body. The weakness recurred twice the following day. After the patient sought medical attention, imaging of the brain revealed only normal anatomical findings, but a Doppler study demonstrated the presence of turbulent blood flow. Blood normally flows smoothly, and this turbulence indicated the likelihood of a blood vessel spasm. This was confirmed by an angiogram, in which X-rays are used to examine the blood vessels after the patient is injected with a substance to make the blood vessels dark. The patient became unable to speak and confused. When her condition failed to improve, she was transferred to a university hospital, but she arrived there comatose with fixed and dilated pupils. The following day life support was withdrawn. This case is remarkable in that there were no indications of eclampsia or preeclampsia, also called toxemia of pregnancy, in this patient. The case suggests that fatal vasospasm may occur in the puerperal period even without these other complications of pregnancy. (Consumer Summary produced by Reliance Medical Information, Inc.)

The world's worst nuclear power accident occurred April 25 to 26, 1986, at Chernobyl in the Ukraine. The subsequent release of more than a hundred different radioisotopes caused the evacuation [...], Data from the nuclear reactor explosion in Chernobyl and the atomic bomb detonations in Hiroshima and Nagasaki demonstrated an association between ionizing radiation and tumoriogenesis. There is a significant association between external beam radiation and radiation-induced sarcoma. Sclerosing epithelioid fibrosarcoma is a rare form of malignant fibrosarcoma that is low grade and indolent with distinct immunohistopathologic characteristics that usually occurs in the soft tissues of the extremities. A 62-year-old man from Kiev who aided in the cleanup at Chernobyl presented with crampy abdominal pain, nausea, and vomiting. His workup revealed a cecal mass, and the final pathology from his laparotomy confirmed sclerosing epithelioid fibrosarcoma with metastasis to the liver. In addition to a review of the literature, we report the first case of sclerosing epithelioid fibrosarcoma arising from the large bowel. Exposure to ionizing radiation from Chernobyl could have played a role in the development of his tumor. (Arch Pathol Lab Med. 2007;131:1825-1828)