Adamantinoma. A case report with aspiration cytology and differential diagnostic and immunohistochemical considerations.

Fine needle aspiration biopsy of bone lesions is routinely used in the metastatic workup of patients with radiographically suspicious areas. However, caution must be used when interpreting smears from aspirates performed on primary bone neoplasms. These tumors are often heterogeneous, and problems with sampling may be encountered. We report a case of a 25-year-old male who presented with a 3-cm lytic lesion in the tibia. A diagnosis of benign fibroosseous lesion was based on the clinical presentation, radiographic appearance and presence of numerous sheets and single cytologically bland spindle cells. Subsequent curettage of the specimen revealed an adamantinoma with a prominent fibrous component. Most of these rare, locally aggressive neoplasms are located in the tibia. They are characterized histologically as having a fibrous background with islands of basaloid, spindle or squamoid cells. Furthermore, a differentiated, regressing variant with an osteofibrous dysplasia-like appearance also exists. Smears consisting primarily of spindle cells or fibrous tissue may lead to an erroneous diagnosis of a fibrohistiocytic neoplasm, fibrous dysplasia, fibrous cortical defect or ossifying fibroma. Pertinent cytomorphologic features should aid in establishing the correct diagnosis of adamantinoma.     

Evidence for a serum factor that initiates the re-calcification of demineralized bone

The present studies show for the first time that demineralized bone re-calcifies rapidly when incubated at 37 degrees C in rat serum: re-calcification can be demonstrated by Alizarin Red and von Kossa stains, by depletion of serum calcium, and by uptake of calcium and phosphate by bone matrix. Re-calcification is specific for the type I collagen matrix structures that were calcified in the original bone, with no evidence for calcification in periosteum or cartilage. Re-calcification ceases when the amount of calcium and phosphate introduced into the matrix is comparable to that present in the original bone prior to demineralization, and the re-calcified bone is palpably hard. Re-calcified bone mineral is comparable to the original bone mineral in calcium to phosphate ratio and in Fourier transform infrared and x-ray diffraction spectra. The serum activity responsible for re-calcification is sufficiently potent that the addition of only 1.5% serum to Dulbecco's modified Eagle's medium causes bone re-calcification. This putative serum calcification factor has an apparent molecular mass of 55-150 kDa and is inactivated by trypsin or chymotrypsin. The serum calcification factor must act on bone for 12 h before re-calcification can be detected by Alizarin Red or von Kossa staining and before the subsequent growth of calcification will occur in the absence of serum. The speed, matrix-type specificity, and extent of the serum-induced re-calcification of demineralized bone suggest that the serum calcification factor identified in these studies may participate in the normal calcification of bone.     

COMMON LESIONS OF THE URETHRA IN WOMEN

Urethral disease in women and girls often is overlooked. As the urine may seem to be normal as determined by repeated urinalysis, the symptoms—urinary frequency and burning—may be attributed entirely to other pelvic disease or to functional disorder. Since erroneous diagnosis may lead to unnecessary procedures or to neglect of treatment with consequent development of severe disease in the kidneys or ureters, it is important to consider urethral lesions as a possible cause in any case of abdominal discomfort in women.The most common lesions of the urethra in women are urethritis, stricture, caruncle, inflammatory polyps and cysts, prolapse of the urethra, and diverticulum. In some cases diagnosis can be made simply on the basis of inspection and palpation. In others more extensive diagnostic procedures must be carried out in order that treatment may be definitive.The methods of treatment, varying with the nature of the lesion, are outlined herein.     

DIAGNOSIS AND TREATMENT OF JOINT TUBERCULOSIS

Tuberculosis of the joints is not a clinical oddity and a diagnosis of tuberculous infection must be considered in all joint lesions if diagnosis is to be made early. A history of insidious onset of pain, especially if accompanied by pulmonary symptoms or a history of contact with a tuberculous person, should alert the clinician to the possibility of this diagnosis. The tuberculin test, roentgenograms, culture of aspirated fluids and biopsy, by anthrotomy or punch, continue to be the standard procedures for establishing the diagnosis. The differential diagnosis must include the entire gamut of bone and joint disease.Chemotherapy combining streptomycin and dihydrostreptomycin with isonicotinic acid hydrazid and para-aminosalicylic acid is of extreme value in the eradication of draining sinuses and in the advancement of the ideal surgical date; but general physical and mental hygiene, rest and the prevention or correction of deformities is a continuing therapeutic necessity. Fusion of the affected area is advocated in almost all lesions although there is some hope that functioning joints may be preserved with early diagnosis, conservative surgical treatment and more efficient antibiotics. A postoperative regime similar to the preoperative treatment must be continued until the stabilization is firm or until there is no evidence of activity.     

Ectopic lesions as potential pitfalls in fine needle aspiration cytology: a report of 3 cases derived from the thyroid, endometrium and breast

BACKGROUND: Ectopic lesions are rarely encountered. Those that are derived from thyroid, breast, endometrium and salivary glands present with palpable masses that can mimic malignancy. Fine needle aspiration cytology (FNAC) is a practical procedure for the differential diagnosis of such lesions but can reveal surprising images for a cytopathologist. CASES: Three cases of discrete, ectopic lesions at different locations occurred. Case 1 was a 27-year-old woman. Upon diagnosis of a submandibular mass with a diameter of 1 cm, FNAC was performed. The smears showed crowded thyroid follicular cells comprising papillary clusters. A cytologic diagnosis of papillary thyroid lesion was rendered, Histopathology revealed that this lesion was ectopic thyroid tissue with focal chronic thyroiditis. Case 2 was a 38-year-old woman who presented with a painful mass with a diameter of 2.5 cm in the abdominal wall. The patient had undergone cesarean section 3 years earlier. The case was diagnosed on FNAC as low grade malignancy in which an adenocarcinoma/mesenchymal tumor distinction could not be made. The pathologic examination revealed endometriosis. Case 3 was a 31-year old woman who presented with a palpable nodule in the axillary region with a diameter of 1 cm. The patient had given birth 1 month earlier and was nursing. An FNAC diagnosis of lactation ectopic breast tissue was made. The mass disappeared by the end of lactation. CONCLUSION: FNAC of ectopic lesions may prove to be a diagnostic pitfall for cytopathologists. A cytopathologist who encounters a cellularpicturefrom a lesion that is outside the normal anatomic location must use a cautious diagnostic approach. Unless there are clear findings, the cytopathologist must refrain from a diagnosis of malignancy.     

L’ostéomyélite multifocale chronique récidivante: Un diagnostic à ne pas oublier chez l’enfant : à propos de deux cas

Chronic recurrent multifocal osteomyelitis is an inflammatory and aseptic disorder, which can affect any bone and be associated with dermatologic lesions. Thanks to better knowledge, this condition is now more often diagnosed. We present two cases, with and without dermatologic lesions. The whole-body bone scintigraphy allows early detection of lesions and bone biopsy is of great help for diagnosis because it rules out tumor or infection. Disease course can be chronic and recurrent. The treatment of choice is non steroidal anti-inflammatory drugs which can be combined or alternated with osteotropic hormones.     

Salivary Gland Tumors and Sialadenitis in Children—Experience at Childrens Hospital of Los Angeles

Parotitis, hemangio-endothelioma and mixed tumors are the most common salivary gland lesions in the pediatric age group. Carcinoma and sarcoma are uncommon. Rapid growth of a tumor and pain suggest malignant change.A conservative non-operative approach is stressed for most cases of chronic parotitis. Scout x-ray films and sialangiographic examination are useful in differentiating an inflammatory lesion from a neoplastic growth. Total parotidectomy is advised if operation is indicated.A case of spontaneous resolution of a hemangioma of the parotid gland is presented. A less aggressive temporizing plan should be considered with these lesions, as the risk of seventh nerve injury in children is considerable.The treatment of choice for a non-inflammatory tumor is surgical excision, for most parotid tumors are radioresistant. Small masses should be completely excised for pathological evaluation. Incisional biopsy may occasionally be indicated in the case of a large diffuse lesion, for it may be inflammatory and total excision unnecessary. Most patients with chronic parotitis came to medical attention because of a non-tender asymptomatic parotid lump or diffuse swelling.     

Mammography in management of breast lesions

Comparison of the clinical and mammography findings in 101 histologically proved breast lesions showed that the accuracy of each method in diagnosing carcinoma was about 90%, but when taken together an accuracy of 98% was reached. Though mammography was less accurate in the diagnosis of benign lesions, it was found to be a valuable complement in the management of a lesion in the large atrophic breast and for showing an impalpable carcinoma. In mammography of the young dense breast a negative result must be interpreted with caution.     

Lesion radioactivity concentration estimation using dual modality gamma ray/X-ray imaging

Although the use of dedicated gamma cameras in scintimammography permits closer access to the breast and improved spatial resolution relative to conventional gamma cameras, the task of quantifying the radiotracer concentration in the lesion relative to that in the surrounding breast tissue remains challenging because of the lesion-depth-dependent effects of attenuation and collimator blur. We are developing a dual modality scanner that combines digital x-ray mammography and a dedicated gamma camera on a common upright gantry. Here we present the results of a phantom study evaluating the use of the dual modality system for quantifying radioactivity in breast lesions. In addition to assessment of lesion activity, lesion volume estimates are necessary to quantify lesion radioactivity concentration. We have used multiple view x-ray imaging as a means of estimating lesion volume. Using phantom experiments, we have empirically derived a formula for correction of the measured z dimension of the lesion. The error obtained in quantification of lesion activity is approximately 10%. Lesion volume can be assessed with an accuracy comparable to that of lesion activity assessment using five x-ray views. These results suggest that the error in lesion concentration assessment is approximately 14%.     

Intraosseous vascular malformations of the orbit

Intraosseous vascular malformations are rare benign tumors involving the bones of the orbit. The diagnosis should be considered when a patient presents with an enlarging mass fixed to bone in the upper face, and the characteristic x-ray appearance should be looked for on plain films. Treatment is local excision of the bone containing the tumor and immediate reconstruction with autogenous bone.     

A comparative evaluation of the clinical x-ray picture of uremic osteodystrophy before and after parathyroidectomy]

The authors present the results of clinical, x-ray, and biochemical studies carried out in 51 patients with uremic osteodystrophy, treated with hemodialysis, before and after parathyroidectomy. The patients were divided into 4 groups with various patterns of x-ray symptoms. Patients with x-ray signs of fibrous osteodystrophy made up group 1, the second group consisted of patients with a combination of fibrous osteodystrophy and osteomalacia with secondary hyperparathyrosis predominance; the third group, like the second one, included patients with the mixed form of uremic osteodystrophy, but with the predominance of the osteomalacic syndrome; Group 4 patients had no x-ray signs of bone changes, and the diagnosis of uremic osteodystrophy was confirmed by clinical laboratory evidence. Analysis of the clinical and x-ray data before and after parathyroidectomy has brought the authors to a conclusion that such an intervention was effective only in cases with manifest clinical and x-ray symptoms of fibrous osteodystrophy. In Group 2 patients with the mixed form of uremic osteodystrophy and less manifest osteomalacia as against fibrous osteodystrophy, subtotal or partial parathyroidectomy is advisable only in cases when conservative therapy is of no avail and fibrous dystrophy is progressing. Surgical treatment is contraindicated to patients in whom x-ray signs of osteomalacia predominate over fibrous osteodystrophy in the total picture of uremic osteodystrophy; it may result in a rapid progress of osteomalacia.     

Diagnosis of skeletal lymphoma and myeloma by radiology and fine needle aspiration cytology

Diagnosis of skeletal lymphoma and myeloma by radiology and fine needle aspiration cytology From 1986 to 1998, all patients referred to Karolinska Hospital because of a skeletal destruction of unknown origin routinely underwent radiographic examination and fine needle aspiration cytology (FNAC). Among these, there were 83 patients with solitary lesions of the bone diagnosed and treated for myeloma (plasmacytoma) or non-Hodgkin's lymphoma. Review of the series showed that myeloma could not be distinguished radiographically from lymphoma. Nor could low and high grade lymphoma lesions be discriminated by radiographic appearance. The diagnostic utility of plain radiography in the two conditions seems to be confined to the mere detection of a destructive bone lesion and visual guidance for FNAC. The latter aspect, however, is crucial for the application of FNAC to bone lesions. Review of the cytologic specimens obtained by FNAC showed that they allowed a conclusive diagnosis in all 40 myeloma cases and in 41 of 43 lymphoma cases. In 32 of the 40 myeloma cases, the FNAC material could be used for immunocytochemistry, which disclosed kappa or lambda light chain restriction, corroborating the cytomorphological diagnosis. Thirty-eight lymphomas were characterized immunologically and in 35, a light chain restriction could be demonstrated. Our results show that the use of FNAC in the diagnosis of primary myeloma and lymphoma of bone obviates the need for other diagnostic modalities, including open biopsy. A combined approach based on radiology and FNAC, performed as an out-patient procedure, offers rapid and accurate diagnosis of myeloma and lymphoma among patients with radiographically unclassified destructive bone lesions.     

Distinguishing soft-tissue hemangiomas from vascular malformations using technetium-labeled red blood cell scintigraphy.

Soft-tissue vascular lesions in children can be classified as either hemangiomas or vascular malformations. The distinction between the two has important prognostic and therapeutic implications. Over the past 8 years, we have evaluated 64 vascular lesions with the technetium-labeled red blood cell (Tc-RBC) scan. Twenty-eight lesions imaged as hemangiomas with intense focal uniform uptake. This diagnosis was confirmed in 27 lesions, or 96 percent. Thirty-six lesions imaged as vascular malformations with abnormal vessels or diffusely increased activity. This diagnosis was confirmed in 35 lesions, or 97 percent. Overall, the Tc-RBC scan was 97 percent accurate in distinguishing hemangiomas from vascular malformations. It is particularly useful when the clinical diagnosis of the lesion may not be evident. Not only can biopsy be avoided, but parents can be reassured at an earlier age and given accurate information regarding prognosis.     

Usefulness of bone formation markers in breast cancer

The skeleton is the main site affected by metastases and breast cancer is the most frequent tumor to invade bone. The assessment of bone metastases is difficult and biochemical markers of bone formation (BFMs) could be a promising alternative. Although the essential role of osteoblasts in the metastatic process of bone destruction is now well established, little attention has been paid to BFMs. We conducted a Medline search for studies about BFMs in breast cancer. Our review allows us to conclude that BFMs have high specificity but low sensitivity for the diagnosis of bone metastases. The available biochemical markers cannot replace imaging techniques for the diagnosis of bone metastases. Several studies indicate that BFM serum levels reflect total tumor burden in the skeleton. BFM levels are higher in patients with blastic lesions compared to those with lytic lesions. Serial measurements of BFMs could be useful for the clinical assessment of response to antineoplastic treatment or to bisphosphonate therapy. Besides markers of bone resorption, biochemical markers of bone formation are a promising alternative for the assessment of metastatic bone disease, but large prospective studies are needed to address this important issue.     

Characterization of gout in a skeletal population sample: Presumptive diagnosis in a micronesian population

Characterization of the nature and skeletal distribution of gout was accomplished in a Chamoru (Chamorros) population with predilection to the disease. Uniform excavation by the gouty diathesis produces a punched-out appearance to these predominantly monarticular lesions. The lesion is distinct from that seen in rheumatoid arthritis, spondyloarthropathy, or infection. Reactive new bone formation in some gouty lesions also has an apparently unique, ivory-like discoloration (contrasted with the adjacent bone), which facilitates diagnosis. © 1995 Wiley-Liss, Inc.     

Fibrous inflammatory pseudotumor of the bladder

Fibrous pseudotumor of the bladder, a rare, benign, and proliferative lesion of the submucosal stroma, can be mistaken on gross examination for a malignant lesion and must be differentiated on histologic examination from several bladder malignancies. Radiographic examination alone cannot establish a definitive diagnosis. Complete transurethral resection of such lesions appears to be curative.     

Non-dermatophyte Dermatoses Mimicking Dermatophytoses in Humans

Human dermatophytic cutaneous infections usually present as single or multiple slowly progressing annular erythemato-squamous lesions with a tendency to central healing on the hairless skin. In the intertriginous regions (feet, inguinal, axillar, submammary), dermatophytic colonisations and infections manifest as whitish, slightly hyperkeratotic, pruritic and sometimes fissurated lesions. On the scalp, dermatophytic infections commonly lead to single or multiple more or less inflammatory and alopecic lesions. On the plantar and palmar aspects of the feet and hand, dermatophytosis presents as an eczema-like chronic dermatosis. Abscess-like lesions may occur due to zoophilic dermatomycosis. Dermatophytic infections of the nails reveal ill-defined whitish-yellowish colorations of the distal end or the lateral aspects of the nails, sometimes combined with partial nail embrittlement or even complete destruction. Despite the ubiquity of dermatophytic skin infections and their usually highly typical clinical features, a differential diagnosis has to be considered, in particular when treatment is not efficient or when treatment resistance occurs. This review presents the differential diagnosis in terms of frequency as well as the diagnostic methods permitting the distinction of annular, intertriginous, alopecic, palmoplantar, abscess-like and onychodystrophic lesions.     

Vertebral lesions in a titanosaurian dinosaur from the Lower-Upper Cretaceous of Brazil

In this paper we describe macroscopically two types of bone lesions on a caudal vertebra of an indeterminate titanosaur recovered from the Lower-Upper Cretaceous (Albian-Cenomanian) Açu Formation in the Potiguar Basin, Brazil. The first type of lesion corresponds to cystic lesions on cranial and caudal joint surfaces of the vertebral body, which are identified as subchondral cysts. The second type of lesion corresponds to an irregular bone overgrowth located on longitudinal ligament insertion points. This ossification can be associated with an axial spondyloarthropathy or diffuse idiopathic skeletal hyperostosis (DISH). Bone overgrowth on vertebrae is well documented in the dinosaur fossil record, whereas this is only the second case recorded of subchondral cysts.     

PULMONARY SEGMENTAL RESECTION OF SOLITARY LESIONS OF DOUBTFUL CHARACTER

Pulmonary cancer can be diagnosed earlier if patients with pulmonary symptoms of chronic type are given x-ray examination early, if patients over 40 years of age have a yearly roentgen examination of the chest regardless of their state of health, and if those with acute pulmonary illness are examined by x-ray within one month of the onset of illness.Observation of a known intrapulmonary lesion of unknown character should never last for more than one month. If it persists after that period, complete investigation, including thoracotomy, should be carried out if necessary to establish an exact diagnosis. A localized intrapulmonary lesion can be removed by segmental resection so that all healthy functioning lung is conserved if the disease is benign. If, after pathological examination, the lesion is shown to be cancerous, more radical resection can be carried out.